RCGP South West Drug Training

Patient Going Abroad?

2011-05-01T08:31:00.000-07:00

OST patient's going abroad pose a number of issues: is it safe for them to have so much opioid with them at any one time? will they be travelling with children? will the drugs be kept in a safe place? should we give methadone tablets instead of mixture to avoid airline liquids restrictions? all of which have to be balanced against the natural desire for a patient to lead as normal a life as possible and not to allow treatment to detract from their quality of life.

One set of questions which is independent of all these concerns, is how will the country to be visited view the possession of so much controlled drug? the letter which we are supposed to send with patients travelling abroad ensures that they will not contravene regulations whilst within UK borders, but what happens when they arrive in another country? I am indebted to Jon Nicholas, a colleague with whom I work in Somerset, for pointing out a really useful web resource for patients going abroad. This website offers forms in differing languages according to the country being visited, and in the wording that they would like to see. It also has a description of the legal attitude to prescribed CDs for each country. I don’t know how accurate this latter information is, and the advice should remain the case that a letter from us only maintains legality up to UK departure, it remains the patient’s responsibility/risk for the countries they choose to visit – but this resource is at the very least a helpful indication. I suggest you copy the links into your favourites bar.

So, for regulations relevant to various countries, use this link:

And for forms in various languages, use this link:

“Recovery” and the New Politics

2010-11-14T08:50:00.000-08:00

I am sure that like me, you have become fed up with all this “recovery” talk – everyone in the addiction world seems to have an opinion, soap boxes have never been so trammelled, poles have never been further apart, and no one is any the wiser. But in the middle of all this hot air we have had a new government, and some of the whispers emanating from the corridors of power is that they have a very good idea of what “recovery” means to them – and that is off methadone, and off benefits. There has been talk of time limited methadone, and “payment by results” (PBR) which by inference, means being paid for leveraging people out of treatment.

You can imagine the hysteria that sort of thinking creates – from patients who have got used to the idea of being “maintained” on methadone, from lobbyists and advocates who espouse the rights of people to be in treatment, and from the practitioners of harm reduction, who like me are old enough to remember all too clearly the carnage resulting from enforced reductions and punitive practices 15 – 20 years ago.

Well I am as much a pinko liberal harm reductionist as the next man, but I also like playing Devil’s Advocate, so try out this dear reader: within a caseload of patients on methadone, there is a substantial number who will undoubtedly be there for a very long time, and possibly indefinitely – maybe those with serious enduring mental health problems, learning difficulties etc, I am sure we can all think of many who will almost certainly remain safer, more stable and have a much more certain and secure quality of life on their OST. But I think that if we were really honest, we might also identify a number who might, perhaps if we had tried a bit harder and offered more, have gained their independence from methadone, doctors and treatment systems a lot earlier. Harm reduction is such a manifestly good and safe thing to do, that maybe it can become a bit too comfortable for both patient and treatment team alike – whilst we smugly congratulate ourselves on the harm which statistics show we must be doing, perhaps we overlook those with greater resources who might be able to use OST simply as a brief bridge out of addiction and into stable long term non-dependency. I am sure this is the case: maybe there aren’t many in this latter category – but even if it is a handful, then it is a handful who could have been spared years in treatment systems if we had tried that bit harder.

The new government may have its prejudices, but at least it is currently soliciting expert opinion and encouraging discussions before they pronounce on what they want from us – and my view is that if we are to win the argument that there is a place for long term maintenance OST, possibly for the majority, then we will have to deliver “results” by working harder to help a minority to exit treatment.

So if you were to look at your caseload and try to identify “the low hanging fruit” – those who are most likely to be able to achieve durable opiate abstinence, who would they be? Little work has been done on this, but I came across a fascinating paper by Hser et al. “Trajectories of Heroin Addiction - Growth Mixture Modelling Results Based on a 33-Year Follow-Up Study” Evaluation Review Volume 31 Number 6, December 2007 548-563 © 2007 Sage Publications. This is an American study and we must always be careful about comparing apples with pears – the treatment system is very different in the UK to the USA – but this is a remarkable paper if only because it follows nearly 500 heroin using patients over 33 years – so it carries a great deal of rigour, and I very much doubt if there will be anything comparable in the UK in the foreseeable future. The authors identify three distinct sub groups of patients – the great majority (59%) they describe as “stable high level heroin users”, who have consistently maintained regular heroin use since OST initiation. The next biggest group they call “late decelerators” (32%) who maintained a high level of heroin use for approximately 10 years of OST, but then the percentage of nonusers started to increase, and lastly the smallest group (9%) of “early quitters” - These participants decreased their use within 3 years of initial use and stopped using altogether in the subsequent 7 years – so even early quitters still spent a long time in treatment.

So what were the distinguishing characteristics of these “early quitters” I hear you clammer? well I expect your intuition will be born out: third most important characteristic was that they had high “social capital” ie. they had jobs, supportive families and so forth. Second most important was that they started heroin use later than the other two groups, and you might surmise that good parenting helped to “protect” them from heroin exposure too soon. So what was the most powerful predictor of early quitting? Um, well, it was that this group was predominantly white – the other two being predominantly Hispanic or black – this was the USA after all!

And the BMJ goes One Better!

2010-07-24T09:18:00.000-07:00

July 17th issue has a front cover showing a cup of methadone bearing the slogan: "Drug Users and HIV: Treat Don't Punish. Well amen to that, and inside is an editorial asking for an evidence based drugs policy and an excellent article by Steve Rolles titled "An alternative to the war on drugs" - with arguments that many of you might be familiar with if you have followed Transform's activities over the years. There is also a sobering article on the HIV epidemic in Eastern Europe (where methadone prescribing is not available). So, you might think - why is the NTA considering time limited methadone prescribing in the UK? (read the Guardian article here)

I don’t think this discussion from the NTA proposes that we come full circle, to the situation 15 years ago of enforced abstinence and time limited treatment, with its good evidence of being bad practice with poor outcomes. MMT studies over the past 15 years show a gratifying reduction in deaths, crime, and BBV rates – which is excellent, and the NTA would manifestly not disagree with those numbers, nor NICE etc….what I think they are trying to say is what all of us, if we are honest, know – namely that methadone for all its wondrous powers of harm reduction, is just as powerful at motivation reduction – and many patients just drift on for ever in (correctly) non punitive treatment regimes, using a bit of heroin now and again, and leading what most would consider to be very commuted lives, and generally contributing less to society and themselves than they could. Yes of course this is as good a life as is probably possible for those with mental health problems, learning difficulties or whatever ….and yes, if people want to use drugs in a controlled and relatively low-harm way, then I would defend their right to do so…. But politicians and the public have the right to question the bias towards a treatment which seems to preserve inertia (at enormous cost to the Welfare State) rather than facilitate change. We have all got anecdotes of people who are apparently wearing suits, holding down clerical jobs with a Ford Mondeo in the garage and happy children whilst taking 150ml methadone daily, but we have been bloody awful in the past 15 years at collecting evidence of that: the pleural of anecdote is not evidence….and the consequence of our failure to get evidence for what we think, is the problem which now faces us.

The most powerful motivator for an addict to change is the harm that he/she encounters, and methadone nulls out much of that harm which is why we use it. The challenge is preserve external drivers to change, whilst reducing the harm – that is the Philosopher’s Stone of addiction treatment.

BJGP has an interesting issue!

2010-07-04T04:55:00.001-07:00

I thought that might grab your attention! this month's issue has an interesting editorial by Gerry Stimson and others on illegal drug use in an ageing population which pin points many of the challenges we will be facing in the years to come (as doctors that is!). And there is a slightly dry statistical analysis over 8 years of Scottish GPs treating drug users....but showing (with concern but no surprise to me) that "the new GP contract may have decreased GP involvement in treating drug misusers". But the star piece goes to Jenny Keen's group whose paper on a targeted GP led programme to treat addicted sex workers, which at one year recorded 100% of the cohort still retained in treatment, only 33% still sex working, heroin use had fallen and quality of life was enhanced. This is great general practice addiction work, and I suspect that many are doing equally good work elsewhere but Jenny seems to be the only one of us who has the energy, commitment and academic robustness to write papers.

(No hyperlinks I'm afraid, the BJGP is subscription only)

NICE Alcohol guidance

2010-07-04T04:29:00.001-07:00

...has at last been released, and is fairly uncontentious. I think that some of the sections will fill acute Trusts with foreboding, as there is a clear mandate for admission for formal detox in some cases - making the standard policy (in some hospitals) of bouncing drunks out of A&E more difficult to defend. You can read the guidance here.

Loads of Stuff

2010-06-06T05:11:00.001-07:00

This month I am indebted to Dave Targett at Turning Point for making my June Blog entry a doddle- because they have trawled the internet and given me all this inspiration.

The National Audit Office (NAO), have completed an audit analysis of the (cost) effectiveness of the actual government drug strategy and the effectiveness of local implementation. An interesting read that isn’t the whitewash you might expect. Click here to see it.

And here is a meta analysis of motivational interviewing and other psychological interventions in substance misuse - a magnificent effort by the authors on 25 years of published evidence.

Interested in supervised injecting and want to know the international experience? aside from Vancouver, Australia too has had very positive outcomes for its service users - a report can be found by clicking here.

And what about personal budgets? we are starting to get used to these in social care, but a pilot is being run now which aims to see if this approach can be extended to those accessing addiction services - now that should sharpen our act up! Click here to read about it.

Glastonbury festival this week - hurrah!

Conference Marathon completed!

2010-05-03T01:31:00.000-07:00

Your scribe has completed the Grand Slam and been to Glasgow for the RCGP conference, then Liverpool for IHRA and finally Bristol for the RCPsych Faculty of Addictions conferences - all were great fun and very different: the RCGP was as usual a great event for networking, meeting up with old friends and seeing how GP addiction services are progressing around the country; IHRA was a gigantic meeting in beautiful Liverpool - many hundreds of delegates from all over the world to examine international drugs policies on Harm Reduction, with a good deal of time devoted to discussing "Recovery" - incuding Prof McKeganey bravely standing in the lion's den to debate his ideas....and Bristol? well give the RCPsych Faculty conference a try folks - it is a most exciting forum for discussing science and theory.... I heard a fascinating presentation on designer drugs amongst many others....next year's is in Newcastle - details will follow as usual.

So here's a bunch of links you might like to look at:

Want a bit of fun, and to direct carers and service users for education around overdose? - then click here for "The OD Game" and test yourselves!

For a billion statistics on injecting drug harm and needle exchange etc click here for the IDU reference group.

The British Pain Society's Guide to Opioids for persistent pain is a "must-read" for your CPD - download it by clicking here before they start charging for it!

Stanton Peel, veteran addiction psychologist who is always great value for a speech because of his forthright views, has his own blog which is much more entertaining than mine - click here and you will be whisked over to it.

And finally SMART is a new mutual aid recovery program which is spreading fast and may appeal to some who have, rightly or wrongly, been put off by 12 Step groups - they have a great website, have a look by clicking here.

Not so Legal Highs

2010-04-02T07:57:00.000-07:00

Well our government has once again put media hysteria before science and slapped a ban on mephedrone, miaow miaow, or whatever it is known as.... clearly they have been so impressed with the effect that criminalisation has had on the quantity and safety of consumption of other drugs that it just can't wait for the scientific evidence to deliberate one way or another. It may very well be that this drug is harmful, certainly I wouldn't want to be sticking plant food in my body - but all the evidence of past mistakes would suggest that the act of criminalisation will simply make it more attractive, put the profits up for the black market, and encourage even more dangerous substances to be sold masquerading as mephedrone, or indeed diluting it. ...

Not that I have any confidence that the other lot would have acted any differently.....

RCPsych Conference in Bristol

2010-03-04T05:33:00.000-08:00

This year's RCPsych Faculty of Addiction conference is to be hosted in the South West, in Bristol on April 29 + 30, and is being organised by Alison Battersby of Plymouth. There is a really excellent programme you can see by clicking here, and Alison has asked me to emphasise that GPs with an interest in addiction work will be particulalrly welcome. Clearly Addiction Psychiatry contributes greatly to the theory, knowledge base, research as well as practice of addiction medicine, and if you have ever felt that you need something perhaps more academic and scientific than many of the other conferences, then this could be for you. You can also download the registration form by clicking here. This will be a great opportunity to network with our psychiatry colleagues locally, and share our ideas and experiences.

Anthrax!

2010-02-10T12:16:00.000-08:00

The mini outbreak of anthrax amongst Glasgow injecting drug users has come south - there has been a confirmed case in London. We don't know how these infections have occurred: one can speculate, but it doesn't help much - the fact remains that injecting materials into your body that have no aseptic, regulated, pharmaceutical provenance has, and always will be, very dangerous. just as in clostridial infections we must be alert to abscesses: anything that is hot, spreading, and is associated with systemic upset should be sent to A&E as a matter of urgency, along with a phone call to the (often inexperienced) SHO, with your concerns about something he or she has probably never heard of.

David Nutt strikes back!

2010-01-08T08:26:00.000-08:00

I am delighted to read that Professor Nutt is reconvening like minded experts into a new group, free of government bias, to deliver clear, authoritative and apolitical advice on the safety of drugs. You can read about it here. No doubt the upcoming General Election will have the parties competing for the "toughest" stance on drugs, whilst at the same time planning to disinvest from treatment - if any of my readers have the ear of their local MP, please give them this simple message: the harms that drug use cause health have far more to do with their legal status than the drug itself - and that education and treatment will be far more effective at reducing that harm if they are properly financed, and certainly far more effective than criminalisation.

Scandalous Sacking of David Nutt

2009-11-01T22:09:00.000-08:00

All of you will share my shock and outrage that our colleague Professor David Nutt, has been sacked from his honorary position as Chair of The Advisory Council on the Misuse of Drugs. The principle function of the ACMD has been to examine the body of scientific evidence on the harms that psychopharmaceuticals cause, which in turn informs their status in their legal classification. As a Professor with an international research reputation on the harms that drugs cause, there could be noone better placed to Chair this committee. But you will be aware that the Government has ignored the advice of the ACMD with regard to the downgrading of category of cannabis from B to C, and ignored their call to include alcohol and tobacco in the tables, for reasons that are entirely political. David publicly questioned why the government should appoint a team of experts and then ignore their advice, and for that reason he was sacked. I would not pretend that the legal status of drugs is simple - and acknowledge that public health and behaviour have large political dimensions: it is precisely because the two forces of science and politics apparently conflict that we need to encourage open and honest debate - not attempt to silence it so crudely (and utterly ineffectively). It is ironic that in countries such as Afghanistan, we are trying to promote our notion of democracy: I wonder what they make of our democratically elected government which will sack a man for free speech, and expressing a scientifically based opinion that opposed the stance of political prejudice?

Stop Press - read David Colquoun's excellent commentary in the current BMJ here.

Trailblazers in the Southwest

2009-10-25T10:03:00.000-07:00

Have you checked out the new copy of Network? lots of interesting stuff, much of which has been contributed by you in the South West: there is an excellent piece on Ketamine on the front page from Fergus Law and colleagues in Bristol; an informative article on pain management and addiction in the acute hospital by my colleague and friend Dawn Wintle in Yeovil Hospital (every hospital needs a Dawn Wintle), and an article on Young People's Drug and Alcohol services in Plymouth, By Charlie Lowe and Gerry Woodley.

And a couple of weeks ago I listened in abject admiration to Adam Ellery and Helen Hampton, on how they have set up a Hepatitis C treatment service for their drug using clients in Cornwall. Not (as I assumed) merely a satellite outpost for specialist hepatologists to simply get their medications delivered - but a commissioned, stand alone primary care treatment service for HCV - according to Adam, if you can prescribe methadone then you should be treating your HCV clients at the same time - I am sure this is a most important direction for GP drug misuse services to go in and Adam is showing the rest of the country how to do it well.

Fancy a Job at the SMU?

2009-10-25T09:32:00.001-07:00

The RCGP Substance Misuse Unit is looking for a new Lead for the Part 1 Certificate in Drug Misuse - you need to be able to give a notional session a week and develop the course materials which are constantly under review. Even though the academic satisfaction, not to mention the kudos of working with the RCGP (ahem) would be reward enough for anyone, there is half-decent money attached as well - apply to Jo Betterton at the SMU. And we are also looking for Part 2 Tutors.... if you can spare the time. Ask Jo again...

Release Conference 2009

2009-10-25T09:19:00.000-07:00

Release's annual conference was convened in Derby this year: for those of you who don't know it, this conference is distinctly different to most as it encourages the delegate to think around subjects that we often ignore. This year there was an excellent presentation from the English Collective of Prostitutes - reminding me for one that "the world's oldest profession" suffers many of the same prejudices and criminal persecution that drug users do, for "crimes" that ultimately only affect themselves. John Strang gave an excellent presentation on naloxone prescribing, and the follies of the legal status of naloxone - something I have banged on about before. We heard about drug consumption rooms and their success in a number of countries around the world (but still not the UK), the upcoming Welfare Reform Bill and many other interesting and important presentations. If you haven't been to a Release Conference then you should - excellent CPD and more mind expanding than most.

15TH NATIONAL RCGP CONFERENCE

2009-09-09T10:32:00.001-07:00

RCGP SEX, DRUGS AND HIV TASK GROUP PRESENTS

Working with Drug and Alcohol Users in Primary Care

Integrating Practice and Policy: Everyone’s Business

THURSDAY 22 AND FRIDAY 23 APRIL 2010 | SECC GLASGOW

“I look forward to this conference all year because there is genuine debate wth all views being heard and considered and it is full of people who genuinely care’’ _{USER ADVOCATE APRIL 2009}

The largest event in the UK for GPs, shared care workers, drug users, nurses and other primary care staff, specialists, commissioners, and researchers interested in, and involved with, the management of drug and alcohol users in primary care.

Building on the success of past conferences, this long-standing event returns now, for its 15th consecutive year, to examine the critical role primary care plays in working with drug and alcohol users, their families and carers.

The two days focus upon integrating practice and policy, exploring the challenges, benefits and developments in practice today, with a Scottish flavour. Through an ensemble of over 40 factual, interactive and educational presentations, select special interest sessions, presented papers and films delegates will have the opportunity to explore a variety of topics including:

Exploring the recovery debate and personalisation of treatment
Redefining harm reduction
Integration of the whole treatment system
Discussing linkage between use of substances, deprivation, social exclusion and poverty

KEYNOTE SPEAKERS INCLUDE

Marcus Roberts Director of Policy Drugscope
James Egan Head of Policy and Practice Scottish Drugs Forum
Roy Robertson GP and Reader University of Edinburgh
Anne Whittaker Nurse Facilitator (Drugs/Alcohol/BBV) NHS Lothian

The conference also includes an exhibition and poster display throughout the event and a taste of Scotland reception and evening function on day one - an opportunity to further discussions and share personal knowledge and experiences with fellow attendees and speakers.

This highly popular event is a must save diary date for all professionals and anyone involved or interested in this complex area.

For more information about the event, or to request a conference brochure, please contact Hanisha on 020 8541 1399 or emailhanisha@healthcare-events.co.uk

What to do with over the counter addiction?

2009-09-05T01:40:00.001-07:00

What to do with over the counter addiction?

Thursday 21^st January 2010

York Hotel York

A day to discuss OTC addiction:

• What is the size of the problem?

• What is the evidence?

• What are the best treatments?

• What does the updated Clinical Guidelines say?

• How do we best manage OTC addiction in general practice?

If you are concerned about any of the issues that these questions raise, then this day is for you.

Speakers include:

Dr Deborah Noland, GP Brownlow Group Practice Liverpool

Richard Cooper Lecturer in Public Health, University of Sheffield, and community pharmacist

Dr Chris Ford- GP SMMGP Clinical Lead and CPD Lead SMU

Payment information:

Past and current certificate candidates: £130.00
All other delegates: £150.00
Please reserve your place before sending payment
Payment is by cheque only and must be in the SMU office by December 18^th2009 at the latest
Cheques should be made payable to the RCGP and sent to c/o Jo to the address below

Please note:

Refunds for cancellations or non attendance are not available unless another delegate fills your place

For further information or to reserve a place please contact:

Jo Betterton (020 7173 6095 jbetterton@rcgp.org.uk) SMU, Suite 314,

32-38 Leman Street, London E1 8EW

2009-08-01T09:03:00.001-07:00

At very long last, the RCGP's much trumpetted Alcohol Certificate is up and running. In a similar way to the Part 1 drugs Certificate, you need to complete some online emodules, but on this occasion these have been created by the DoH - you can have a play with them now by clicking here. There are two upcoming Face to Face events which are likely to fill very quickly, so book early to avoid disappointment. There is one in York on 24.9.09 you can enrol by clicking here, and one in London on 19/2/2010 which you can enrol on by clicking here. We can only hope that PCTs will bow to the mountain of public and media pressure to follow this up with some meaningful Alcohol LES commissions - however with the public purse being drier than a Pharoe's sock, I am not holding my breath.

2009-07-01T13:34:00.000-07:00

Odds and sods this month folks: I can tell you that the RCGP alcohol certificate is almost there.... it has been tested to destruction by sages the length and breadth of the land and I suspect that I will have something concrete to tell you next month.

But I urge you to click on this link to see my good friend Sebastian Saville, CEO of Release, being interviewed by a Commons select committee on cocaine supplies in the UK. Sebastian is forthright and robust in his parrying of somewhat inane questions fom our political overlords.... I confess that even though I share every sensible person's loathing of the harm that current drugs laws create, I still struggle to see any alternative that causes any less harm.... but at least we have to talk about it in a mature way.

And if you have any patients on higher methadone doses and are worried about QT issues (Blogs passim) I have found a TERRIFICALLY useful web resource. Click here and you will find pages of useful information, drug interaction tables, patient information leaflets etc. Remember: this may be a rare cardiac complication of methadone treatment, but now that it has been recognised we are obliged to take it seriously.

Finally I can tell you that I have been working on drawing up some pragmatic guidance on dexamphetamine prescribing for many months and the work is nearly complete - it is certainly not for the neophyte or the faint hearted.... but someone has to give it a go.... watch this space.....

2009-06-10T10:28:00.000-07:00

I am wondering how the recession might impact on drug services. The barrage of doom and gloom we hear daily in the news would have us all believe that the country is destitute, all government spending will be slashed, and all our patients must get out to work or have their benefits withheld. And yet surely there can not be any other branch of medicine that is more cost effective? whilst we are all stuffing seven million drugs down the (unwilling) throats of hypertensives and diabetics at enormous cost, simple treatment for heroin dependency saves a fortune to the public purse by every measurable criterion since such things were first measured 40 years ago.

But of course treating heroin dependency is not a great vote winner - and all our politicians are trying to curry favour with the electorate at a time when very few of them emerge with much credit from one scandal or another. So we all have a duty to remind all the opinion formers and anyone with any public profile exactly how important this work is.

New this month? check out the NTA's potted "Story of Drug Treatment" - it's a good read and you can get it by clicking here. And opposite check out the new DS Daily in the links bar from our friends at Drugscope.

Bank Holiday Scripting

2009-04-09T07:35:00.000-07:00

This is the time of year when FP10MDAs bounce back from pharmacies with (in my case) alarming frequency - causing distress to the patient, embarrasmment to the pharmacy and annoyance to me. So remember the golden wording which you can get your computer to add to EVERY FP10MDA you ever print from now on:

"Instalments on pharmacy closed days may be dispensed on the day immediatley prior to closure"

you won't ever have to worry about bank holidays or even Sundays ever again!

Whither (or wither) Shared Care?

2009-03-31T11:00:00.000-07:00

Over a decade ago, there were just a handful of GPs in the UK who were delivering quality prescribing interventions to heroin users. Since the College created the Substance misuse certificate, more than 1,500 have completed the full certificate (PwSI level) and more than 6500 have completed the Part 1 and are actively involved in Shared Care - a fantastic achievement. In the UK today, more patients are getting their opiate replacement therapy from their GP than from a specialist service.....so why my double-entendre with the word "whither"?

I am worried: I feel a very subtle change in GP's attitude to working with drug users. Certainly many of the old prejudices have been allayed: this IS work that GPs can and should do effectively; it is NOT neccessarily a specialist concern; GPs WON'T get swamped or get into trouble; and treatment DOES work, it reduces mortality and morbidity to the individual and the family. These essential messages are now widely accepted and yet I feel it is becoming increasingly difficult to engage GPs in this work - why? well the GP contract has made GPs very well paid, and very busy: it has fostered a very commercial attitude to our profession, which is probably for the most part, a good thing - but more importantly, it has allowed GPs to opt out of areas that although worthy, are just too onerous and not well enough paid - notably out of hours care. And increasing numbers of GPs I fear are taking a similar view to the care of drug users: it's worthy, but just more work than I need - and that is a tough argument to oppose.

So I urge all of you who value this work and who read this column to spread the word - enthuse your colleagues - yes it can be challenging at times, and yes the money is crap compared with other revenue streams - but this work changes lives in ways that almost no other medical intervention can do - it is rewarding in ways that money can never be, and it is bloody good fun. We learn from each other, so get out there and evangelise!

Alcohol Training

2009-03-03T10:35:00.000-08:00

The Department of Health has published a new website for training health professional about alcohol - and it's rather good. You can see the pilot pages by clicking here, and soon there will follow an e-module self testing quiz as well. I can also tell you, as intimated in previous posts that my colleagues at the RCGP are working on an alcohol certificate which will link into this e-learning, and it is hoped that this will be ready later this year. At last it seems that that core competencies and acreditted training for GPs are being identified, we can only hope that resources will be found to support GPs with this work. I'll keep you posted.

Talking Drugs Website

2009-03-03T10:29:00.000-08:00

I am delighted to inform you about a new website hosted by that excellent charity Release: TalkingDrugs is exactly that – let’s talk about drugs. There is a huge, largely untapped audience of ordinary people around the world whose communities are being let down by failing drug policies. We believe that many of these people would like to see more economically and socially sustainable strategies for the control of illicit drugs.
TalkingDrugs will harness the immense power of these everyday human voices, bringing the issues alive through the recounting of their own experiences. The use of humour and satire will be key to engaging a wide variety of people who may, up to now, never have given this subject much thought. The Internet makes possible the global sharing of these narratives, encouraging the development of a cohesive and powerful voice through the use of video, photographs and multi-lingual text, allowing geographically and linguistically separated communities to communicate and interact.
TalkingDrugs is a unique participatory mechanism for global dialogue and action on drugs and drug policy – see for yourself and get involved by clicking here - and please let others around the world know about this website.

How fast should we Detox?

2009-01-25T09:22:00.000-08:00

Here's a question with no answer in science: so your patient says "Yes", now is the time to wean off my dependency on methadone/buprenorphine/heroin etc... so how fast should you do it? Some favour the "Grasp the nettle" approach and just get it over with as quick as possible - others, believeing that stepping off a cliff will hurt whereas a gentle if long-winded descent will be much more bearable, favour the latter.

As a paragon of client-centredness I have always gone with whatever my patient feels most confident with, but my inner prejudice, based on overseeing many thousands of detoxes over the years, is that the quick rough ride, maxed up with lots of motivation and support, is the better way: it seems that over a long period of painfully drawn out reductions, something inevitably happens that sets the client back.

So I was interested in a piece of research in Addiction Vol.104 Feb 2009 by Ling et al in the USA that compared the outcomes (in terms of total abstinence) of 7 day and 28 day taperings of buprenorphine... and basically there was no significant difference, both groups maintaining around 13% abstinence at 28 days - which on the one hand appears disappointing, on the other could be seen as encouraging. The authors conclusion being that: "there appears to be no advantage in prolonging the duration of taper."

2009-01-03T01:56:00.000-08:00

Happy New Year people - thank you for looking at these pages again. What do have we to look forward to on 2009? Well, I think that many areas are looking at developing alcohol services in general practice, and I look forward to telling you more about the RCGP Alcohol Certificate training when it becomes available.

I hear from some quarters that Primary Care has never been busier, with all manner of pressures on time and resources, and sometimes it might seem that substance misuse is yet another niche piece of work that is more trouble than it's worth: others however remind me that there are few areas of medicine where it is possible to make so much difference to someone's life, so easily - and it remains one of the most rewarding aspects of a GP's life. So keep the faith, and keep on top of your CPD - I hope to meet many more of you this year. You can keep an eye on the upcoming training events on the right which are continuously updated - and please, if you have anything that would be of interest to colleagues in the region, please contact me and I'll post it.

PS: For those of you not lucky enough to get to APSAD (no, me neither) - there are some excellent presentations now available on the web (click here)

Alcohol at last

2008-12-09T10:18:00.000-08:00

I have been neglecting you, for which I apologise.... the months whip around and before you know it, I am behind on posts by 2 months. So what is new? well at last alcohol seems to be getting some priority: the pathetic little DES for screening new patients is sure to be followed up with locally commissioned more serious interventions, and I am pleased to report that the RCGP SMU is "on the case", and an Alcohol Certificate should be introduced next year: it will aim at screening, brief interventions, community detox etc and will be kite marked and DANOS referenced, we are very excited about it - watch this space.

Drugs and The Law

2008-10-22T10:36:00.000-07:00

Here is a REALLY useful resource which many of you would benefit from: Release, which has campaigned tirelessly to reform drugs laws over the past 25 years, has produced this excellent booklet. It is a very pragmatic and easily accessible document which gives exellent and authoritative advice on all matters pertaining to the subject, including advice on criminal records and employment, a step by step guide through the process of Court appearances, Police powers, the legal classification of drugs and much more. Make sure that you have a copy in your practice library, end even more important, make sure that your Shared Care worker has a copy available at all times - better still, buy him/her a copy as a Christmas thank you present for all their hard work. They are available online or on paper, and Release need your support and donations - click the link on the right and contact them.

Prescription Wording

2008-09-01T11:23:00.000-07:00

Possibly the most miserably tedious bit about the work that we do, is writing out FP10MDAs - we are bound by the most absurd and pedantic regulations - and any slight straying from the rules places the poor pharmacist at risk of censure from his monitors, and our patients at risk of having their essential medication stopped until a properly worded script is obtained. I am grateful to my colleague Nigel Modern for preparing templates for methadone and buprenorphine in Rich Text Format which make the whole business of prescription writing easy and legal - if you would like me to send them to you, then please email me: gordonmorse@gmail.com . They can be used on any computer system and all your problems will go away - now that is something useful from this Blog at last!

To check whether the wording on your templates is concordant with the latest from the DoH, look to pages 106 and 107 in the 2007 Guidelines.

CHRISTMAS SPECIAL!!! Don't forget to add the magic words to scripts over the Holidays: "Instalments due on pharmacy closed days may be dispensed on the day immediately prior to closure"

Conferences, conferences

2008-07-31T12:43:00.001-07:00

OK - so you a re a very busy GP and have little time for your family, let alone feeding your brain.... but your career depends on you being both up to date, and refreshed after taking time out to relax, to be stimulated and to hone your skills. So treat yourself to a conference or two.... and this year in the South West you can treat yourself to two excellent events: the SMMGP annual conference rotates around the UK and this time it is our turn. And the South West regional Shared Care conference also has a particularly strong line up of presentations. And finally, don't forget the Release conference - where you can get radical, get educated, and get objective.... I wont prioritise these excellent events because they are different and are all excellent .... and sadly even I can only get to two of them.... so you all make sure that you get to at least one.... see you there.

STOP PRESS - you can get ALL the presentations at The 2008 National Conference on Injecting Drug Use by clicking here thanks to those marvellous people at Exchange Supplies.

Buprenorphine in Overdose?

2008-06-30T10:04:00.000-07:00

Fellow devotees of "Addiction" magazine will have shared my fascination for a case report in this month's edition of a heroin addict whose life was apparently saved by the timely administration of buprenorphine by his mate..... as we all know, most injecting heroin users have themselves experienced overdose or been with someone else who has, and the majority of most overdoses that end up dead are witnessed long before calling an ambulance. This has led many to distribute naloxone injection with education to those in treatment, so that they can identify signs of overdose in others, and administer it before emergency services arrive.
But this is the first time I know of where a resourceful user (on take-out bupenrorphine) recognised the state of his friend with the blue lips, crumbled up one of his tablets and placed it under the tongue of his unrousable colleague. The subject woke up "all angry" within 10 minutes....
We all know of the paradoxical antagonism of buprenorphine at dose initiation, and this of course makes sense.... I wonder if we can make better use of this "off piste" use of buprenorphine?

“Recovery” – what’s in a name?

2008-06-13T06:24:00.000-07:00

Some of you will have been bored by me banging on from various platforms, about the idiotic mud slinging that goes on between the ultra orthodox abstentionists, and the similarly entrenched harm reductionists. The slurs of danger and ineffectiveness have reached the public whose knee jerk take on all this, is that treatment of drug misuse simply doesn’t work.
In an attempt at some sort of mutually agreeable interpretation of the word “recovery”, Professor John Strang and various professionals and service users from ALL across the divided treatment spectrum got together in a smoke filled room for two days to thrash it out. Known as the UKDPC Consensus group, this is what they came up with:

Recovery is a process, characterised by voluntarily maintained control over substance use, leading towards health and well-being and participation in the rights, roles and responsibilities of society.

And I rather like it. It means that recovery, being a continuous process of accruing benefits, may begin well before abstinence (indeed abstinence may never occur in some cases, despite big recovery gains), and similarly, there may be further recovery to take place after abstinence has been achieved.

So that’s the end of the arguments then………..!

Ketamine

2008-06-01T04:01:00.000-07:00

Either I am just looking for it, or there really is a phenomenon going on out there.... I seem to hear of more and more people using ketamine. What was once just one of many chemicals used occasionally at raves seems to be becoming much more widely used. You will recall that it was popular with anaesthetists as a safe short acting anaesthetic that didnt depress respiration - but because many people found the onset of anaesthesia very frightening, reporting hallucinations, nightmares and out of body experiences, it fell from favour but was taken up by vets, presumably because either animals like dissociative experiences, or more likely, they can't tell us about them afterwards.

But clearly some of our patients love the stuff: usuall snorted, it can cause an unpleasant inflammatory sinusitis, and if injected, getting the dose right is tricky or anaesthesia follows rapidly and you can injure yourself. Long term heavy use often causes a painful and non infective cystitis. But noone seems to know what more harms can follow the use of this drug, and perhaps websites such as this can help. So if you have come accross any stories of ketamine related harms, please let me know and I will spread the word.

More on QT

2008-05-09T23:16:00.001-07:00

Since my last posting on the subject of higher dose methadone and cardiac arrythmias, there has been a growing volume of whispers on the subject. My sense of the present consensus is that on balance of risk, the benefits of effective methadone treatment far outweighs any theoretical (and very small) risk of methadone itself contributing to ventricular tacchyarrythmias. The advice remains (in the BNF) to exclude a prolonged QT interval by means of an ECG in those taking 100mg methadone daily or more, and if you see a prolonged QT interval, then seek a cardiologist's advice, don't stop the methadone.

But in the current issue of Network, Martin Wilkinson has written a nice and concise account on the subject... you can read it here. Which gives me a chance to plug Network, which you should all read - it contributes to your CPD, is delivered free if you ask for it, or is of course available to read on line.

Hard to Reach or Easy to Ignore?

2008-05-01T21:56:00.000-07:00

I have returned from the Brighton conference - it was good to see many old friends there. This year's events were themed around meeting the needs of diverse and disadvantaged populations - not just the BEMs, but also sex workers, those with learning difficulties, mental health problems and so forth. No matter how sensitive we think we are, we need to be constantly reminded of just how awkward some of our services are to access, by certain corners of the population.

There were many excellent presentations too numerous to mention here. Some will be available on the Healthcare Events website in the near future. And speaking of which, ALL of the presentations at the Exchange Supplies Drug Treatment Conference in Glasgow are available by clicking here - I have mentioned this excellent facility in the past but it is worth repeating: you can see and hear presentations in real time on this web site - if it weren't that you would be missing out on meeting all your friends and sharing in the atmosphere of the event, this is almost as good as being there!

Both of these conferences are always stimulating, educational and provide unique opportunities to relax, unwind, and spend some well earned time out with like minded professionals and clients. You owe it to yourself and your CPD to go to one (or both!) every year.

Important Conference comes to the South West

2008-04-01T10:29:00.000-07:00

Those marvellous people at SMMGP (and if you don't access their web site regularly with all its resources, you should) have chosen the South West to host their Third annual (one day)conference. The theme this year is to be "End of The Line, or Part of The Journey? - How to Optimise Patient Choice and Opportunity". This will be an important event for the hitherto neglected South West, and will appeal to GP and all practice staff, as well as Shared Care workers, patients, carers and all those involved in services. It's at The Bristol Marriott on Friday September 26th - stick it in your diaries NOW! it's a day of CPD, and a chance for us all to get together to show the rest of the UK how things should be done! You can go to the SMMGP conference and events page by clicking here and scroll down to the Bristol event....but look at all the others as well.....

Addiction and The Family

2008-03-13T11:01:00.000-07:00

Here is an interesting looking local conference: "Addiction and The Family" - a one day event in Bristol at The Marriot Royal Hotel on Friday November 21st. Speakers include the eminent pioneers of Family Therapy and SBNT, Professors Orford, Copello and Velleman, as well as Prof Moira Plant included in a stellar cast. Details available from Jan.Green@uwe.ac.uk

Personal News

2008-02-29T04:35:00.000-08:00

Your scribe is about to undergo a seismic change in his work: I will continue as the RCGP Drug Training Lead in the South West, but have resigned from 30 years as a GP, 15 years in Clouds House and 5 years as Trust Specialist to the Wiltshire SDAS, to take up a new challenge in Somerset.

This means that Clouds House needs a new doctor - if any of you would be interested, please contact them kirby.gregory@actiononaddiction.org.uk - they are marvellous people to work for and the work is fascinating.

The New Drug Strategy

2008-02-29T04:29:00.001-08:00

Well it is here - the "new thinking" from the DoH. The Daily Mail hacks have already subverted the key messages with cheery messages for their readers that promise to get the junkies off their backsides by removing their benefits if they "fail" their treatment.... oh dear.

Anyway, give it a read, you can be linked over to the documents by clicking here.

Should Heroin Be Prescribed?

2008-02-01T06:25:00.000-08:00

This debate is featured in the BMJ Jan 12 2008, you may like to give it a read. Notwithstanding the considerable cost, and the complexities of supervised injecting and diversion, the experience from studies in Switzerland and Holland have revealed a range of benefits to justify a limited place in our already limited range of treatment options.

Professor Neil McKeganey, never one to shirk controversy in the addiction treatment policy arena, gave his characteristically forthright view that we should not be contemplating this option: “If you can not stop addicts committing crimes to fund their drug habits, then, so the argument goes, the next best thing is to provide them with the drugs thatt are the reason they are committing crimes in the first place. The logic may seem faultless, but at the back of your mind is the nagging question – is this treatment, or is it social problem prescribing?”

My own view is that it is probably both, and in the spirit of harm reduction, I would defend a limited place for diamorphine prescribing, albeit not by me. But my “nagging doubt” is that this is a further step down the road of the medicalisation of drug dependency – a further tacit acquiescence to addiction being some sort of disease that actually reinforces the misguided belief that drugs are needed - rather than their use being a symptom of a more fundamental malaise.

But give it a read – it is thought provoking.

Why We Do What We Do

2008-01-01T23:30:00.000-08:00

Compliments of the season folks. Like many of you I am sure, I spent my time seeing the New Year in, reading the latest copy of “Addiction”. There was a very interesting commentary titled “Why we do what we do” in which the author questioned the “received wisdom” of frequent attendances being required of drug users on maintenance prescribing, and I reproduce some of it here:

“….Perhaps the issue is not so much about whether required clinic attendance is good or bad for patients, but about why we do things the way we do. Could it be that at some level we recognize that requiring frequent clinic attendance is a burden on our patients but we make these requirements for other than research-based reasons? Perhaps we do not trust our patients enough, perhaps with good reason, or perhaps traditional treatment approaches are overly reflective of societal expectations more than based on scientific rationale. Even if we clinicians consider these matters consciously, we are unlikely to engage patients in the process. We do not say to our patients that we understand it is a burden to attend clinic, but that it is necessary because society wants us to adhere to certain expectations in order to improve outcomes, ostensibly to exert control, or for whatever reason. In the final analysis, we can only do what ‘Big Brother’ lets us do according to regulatory mandates. In that context, the real message is that we believe addicts are sick and need help but they are also sinners and must suffer a little, whether by required clinic attendance or supervised dosing or providing urine samples: but that ‘suffering’ may not he entirely bad. While the first principle of medicine is that the patient’s best interests are paramount, sometimes the needs of the greater society conflict with the physician’s judgement about what is best for the individual patient. This is particularly pertinent to addiction, which affects not only the individual, but society as a whole. In such cases it is perhaps also our responsibility to convey to our patients that giving consideration to societal needs is an integral part of their recovery, because in the end they will have to live as a member of that same society with its structured mandates, laws and expectations.”

I confess that this made me feel very uncomfortable – it seems to suggest that frequent attendances are “regulatory mandates” and are primarily designed to control and importune our patients rather than be in the interests of their health. And what is more, that this is allowable because the requirement is (allegedly) helping to shape the patient from social deviancy to social conformity. Does anyone agree?

On the QT

2007-12-03T10:06:00.000-08:00

High doses of methadone can cause sudden death from acute ventricular tachyarrythmias... or at least that is the impression that some research seems to imply. This is known by some cynics as "Krantz Syndrome" after the author of one of the most influential pieces of research on the subject (click here for abstract).

Krantz's postulate is that some people have naturally prolonged QT intervals on their ECG, which is associated with "Torsade des Pointes" arrythmias. In his study, methadone patients further increased the QT interval, but his patients were complex medical subjects, most of whom were being treated for intractable pain and not regular addiction patients at all. In his first report of 17 cases from US and Canadian pain centres, none of whom died, 15 had pre-existing risk factors for arrhythmias. Also, the mean dose was a ‘stratospheric’ 400mg. Other researchers have confirmed the findings, again in very high doses of methadone not normally used in addiction work. Krantz himself concluded that routine ECG examinations in normal addiction patients was not indicated.

However, the BNF and the new guidelines suggest that in methadone maintenance where the dose of methadone rises above 100mg daily, an ECG should be performed. What you do with patients whose QT is prolonged (>440 msec in males or >470 msec in females) is not stated - but clearly other drugs that can also affect either the QT interval or methadone metabolism, should be avoided.

I suspect that this advice will be officially debunked in the future, but for the time being, that is the advice. You have been told!

2007-11-16T05:16:00.000-08:00

Those marvellous people at Exchange Supplies have posted all the presentations for the 2007 National Conference for Injecting Drug Users on their website. You can read abstracts, see the slides and even hear the speeches in their entirety - this was an excellent conference from an excellent organisation, who we have to thank for giving us all access to the presentations without even having to attend. Click here to be taken to the webpage.

Drug use in Australia

2007-11-05T09:09:00.001-08:00

I have not long returned from a visit to Australia, where I attended an interesting conference on methamphetamine. We haven't seen much use in the UK yet, and I wonder whether the Fleet Street prophets of doom will be right with their gloomy predictions - my suspicion is that "Ice" will not become the problem here that it has been in Oz, South East Asia or California - why? well fascinatingly the demographics and the harms with Ice are very similar to Crack - in Australia there is little Crack because there are no traditional smuggling routes and cocaine there is very expensive - in the UK our patients have pretty much open access to Crack or amphetamine and market forces have directed the vast majority of stimulant use to Crack. It is my belief that if we had similar access to methamphetamine, then the amphetamine users might opt for it, but the Crack users would stick with their rocks - but that is just my theory.

Another interesting Australian experience which again arises from traditional smuggling routes is that their heroin is the white water soluble product that is processed in SE Asia and China - so their injecting users are spared the task of cooking up their smack with citric etc as our patients do with the brown Afghan product.

Some Australian commentators have been critical of British heroin treatment, citing low methadone doses and not enough supervision - and I was interested by the comments of one Australian drugs worker who described her country's habit of putting people on daily supervised consumption for ever with virtually no other support, and herding them all into centralised dosing clinics as "a sheepdip" - an interesting antipodean metaphor!

The New DoH Guidelines are out now!

2007-10-01T07:04:00.000-07:00

Yes folks, they have finally arrived, and you can click here to be whizzed over to the NTA Thought Police where you can download your very own copy of your new bible! It is actually a very useful document, so don't just stick on the library shelf to gather dust, read it! and feedback any comments that you have, but you can click here to read the SMMGP quick guide and commentary to all the changes in a special "Network" issue.

The NTA is currently touring England's regions and delivering key messages and important changes in the new guidance - I attended the one in the South West and very good it was too. I saw many of you there, but for those who missed it, you can view their slides here:

Weights and Measures

2007-09-07T07:42:00.000-07:00

Drug users confuse us with many things, but I particularly struggle with their weights and measures, because they insist on using both metric and imperial measures, and dress it all up in confusing jargon as well. So I am indebted to friends who have given me a Tutorial, and I pass this on to you. When dealing in heroin, cocaine and Crack cocaine, the following measures apply:

28g = 1 oz , 7g = ¼ oz , 3.5g=1/8 oz, and a “teenth” (ie. 1/16 oz) should contain 1.75g, but is usually more like 1.5g {NOTE for dealers: a “Nine Bar” is 9oz (250g), and there are 4 Nine Bars to 1 kilogram (36oz)}

So, a typical £10 deal, bag, or wrap of “product” will contain 0.15-0.4g of drug (note the wide range of purity). (Also note that you cannot equate ANY amount of heroin with an “equivalent” dose of methadone for reasons of purity and the variability of individual physiology). So a typical heroin habit that costs, say, £30- £70 per day will involve doses ranging from 0.5g to 1.5g a day, which is…. errrr…. a teenth.

Cocaine and Crack: A dealer will begin with a large amount of powder cocaine, say 1 kilo, or a Nine Bar. Nine Bars of good powder cocaine cost £8000 wholesale. This can then be “re-pressed” (cut or diluted) with a pharmaceutical inert powder called Mannitol, costing £50 for 1kg. An ounce of good powder cocaine might cost £1100, but re-pressed powder cocaine might be £800. Most cocaine sold in ounces or less will have been re-pressed.

Crack cocaine is the free base of (powder) cocaine hydrochloride. “Freebase” Coke is essentially Crack that has been “washed up” (the manufacturing process) using ammonia and ends up weighing less than the original powder weight. Traditional street Crack however is a gain in weight due to the addition of bi-carb, hence the high profit for dealers. The purer the gram of coke, the more weight is returned. 1oz of powder (cost £800) can be turned into £1400 of Rocks if sold in £10 amounts. This can be injected, broken down using frightening amounts of citric, but really its designed to be smoked

Cannabis: The best value in dealing comes from buying Grass in kilos I am told – apparently you can double your money.

The Treatment Outcomes Profile

2007-09-05T10:47:00.000-07:00

Have you heard of this? do you care? well as a GP it wont affect you much yet - but I have a sneaking suspicion that it may in the future. The "TOP" (the unfortunate clash of acronyms has clearly not bothered the NTA whose knowledge of gynaecology I would imagine is scant) is a simple new scoring tool to assess patient progress in treatment. Like the NDTMS data set, it is (at the moment) the job of your Shared Care worker to complete. So why would a GP need to know about this? well I can imagine some PCTs making the completion of these three monthly forms part of your LES, particulalrly if you are a more advanced GP who might start a patient on treatment before the Shared Care worker is involved - or you might be required to fill them in if you are supporting a patient's abstinence and the Shared Care worker has withdrawn.

But fear not, the form is easy and quick to fill in - and should provide some pragmatic and useful data on the value of treatment....Well MOST of the data is useful - but one question asks "How many "Spliffs" does the patient smoke a day!!! for Heaven's sake! are we talking Fat Ones? Four Skinners? A Camberwell Carrot??!!

I don't think that any GPs yet need to be involved in this new bureaucracy - but if you happen to be the sort of proactive, anally retentive sort who wants to know everything that is going on, then click here and you will be beamed over to the NTA documentation and you can read all about it.

Afghan Heroin production soars

2007-08-31T06:34:00.000-07:00

Apparently the amount of Afghan land under poppy cultivation has grown by 21% in the past year - whatever our beleagured troops are doing in that tragic country, clearly any efforts to reduce this trade has been unsuccessful. But to tell an Afghan farmer not to produce one of the few things that has a chance of making any money, seems a bit fatuous anyway - it is in effect punishing him for meeting the demands of our own people. As Simon Jenkins said in The Guardian this week, the ONLY hope for reducing the problems of heroin consumption in the West are to reduce the demand by more investment in treatment and in addressing social exclusion. Attempts to curtail supply have never worked, anywhere, ever.

In the meantime I guess that this increase in heroin supply will be translated into our practices in the year ahead in terms of stronger purity for the same cost - we shall see.

25% Rise in Drug Related Deaths in Scotland

2007-08-31T06:17:00.000-07:00

This news from Scotland is depressing:

Scotland you will remember was at the vanguard of introducing supervised methadone consumption in response to its appalling rate of drug related (and methadone related) deaths in the late 80's - the fall in deaths that followed was further evidence of the value of high quality methadone prescribing. And it was Scotland's heroin users who discovered the value of buprenorphine as well in the great Scottish Temgesic "scandal" which led to the CD Classification of buprenorphine and later, in a poetic twist of irony, to buprenorphine receiving a licence for the treatment of opiate dependency. And it is Scotland where high doses of methadone are championed, and where just last year, some Chief Police Officers were calling for a return to abstinence treatments because of the "failure" of methadone programmes! what a confused state of affairs. It is remarkable that since Dole and Nyswander first wrote about methadone treatment in JAMA in 1965, every single study published has reinforced the message of the life saving effects of high quality substitute prescribing - I hope that Scotland does not loose sight of that message - whatever is going on in Caledonia to increase the rate of drug related deaths now is evidence (if we ever needed it) of the need for more treatment, not less.

http://www.drugscope.org.uk/newsandevents/currentnewspages/Scotland_DRD_rise.htm

Suboxone on FP10MDA

2007-08-17T07:33:00.000-07:00

There was a minor cock up when this drug was put on sale in the UK - there was some sort of legal reason why it should not be prescribable on "Blue Scripts", making interval prescribing impossible. Soon after there was an unofficial dictat sent out to pharmacists for them to accept Blue Scripts (and be paid for doing so), but now I am happy to tell you that the situation is resolved and it's official, Suboxone MAY BE PRESCRIBED ON FP10MDA - hurrah.

Of course this drug's major selling point over buprenorphine (without naloxone included) is that it is less likely to be diverted because it has no appeal for injecting - so ironically, you might be more inclined to take the patient off supervision more quickly and onto less frequent collections to save the poor old PCT's cash.... and the latest edition of "Addiction" (102) has a study by Prof Bell showing that unsupervised Suboxone is every bit as effective at retaining patients in treatment as supervised buprenorphine - something to ponder.....

"After The War on Drugs"

2007-08-15T09:51:00.000-07:00

Our friends at Transform have produced a new document that you may be interested in. Titled: "After the War on Drugs: Tools for the debate" is a guide to making the case for drug policy reform designed to:

Re-frame the debate, moving it beyond stale ideological arguments into substantive, rational engagement

Provide the language and analysis to challenge the prohibitionist status quo, and to make the case for evidenced based alternatives

You can access it from Transform's Blog here.

As I write, I have just spent a day attending to casualties of this "war" - including one chap who was released from prison with no methadone, no benefits and no home to go to. He stole a tent to keep out of the rain, is stealing to buy food, and has had two near-fatal overdoses in ten days. If he survives long enough he may live to be sent back to prison again. I am not sure who the winners are in this war, but there seem to be plenty of loosers.

Dalrymple says that Heroin Detox is "No worse than Flu"

2007-08-14T10:17:00.000-07:00

For years, Theodore Dalrymple's writings on all things medical have been enjoyable for their dry wit and keen observations - but when he writes about heroin users he seems to me to loose his normal compassion and humanity. Maybe he has some personal "agenda".... but anyway....

Dalrymple was plugging his new book on Radio 4 this morning (hear the interview here) but some aggrieved methadone patient was shouting him down constantly so I did not hear the full argument and I have not read the book.... but it seems pointless to say that stopping using heroin is no worse than a dose of flu - and that it is all "psychological" (as if psychological distress didn't matter), because quite clearly people seem to have a great deal of difficulty coming off heroin which is disproportionate to a dose of flu...... But in another sense of course he is right - traversing an opiate detox can be achieved within 2 weeks by 80% of our patients at Clouds - rather less I suspect if we did not medicalise the event - but then we medicalise flu with aspirin and going to bed as well..... and I also agree with him that by medicalising addiction we turn clients into patients, tacitly suggesting that as "sufferers", they are not responsible for their "disease" ... and the ongoing daily dosing of methadone petrifies that mindset.

But I am not greatly bothered by Dalrymple's prejudices, because when people like him talk about heroin addicts, they talk about heroin, rather than talk about why people become unhappy and look for chemical relief in the first place. Returning to the unhappiness that the chemicals null out is what is hard, not relinquishing the chemicals themselves. Perversely, I am rather glad that we do have heroin and alcohol sloshing around our streets.... for every society has always had inequality of opportunity brought about by intellectual, social, mental and family dysfunction, and that inequality brings about enormous unhappiness. Whilst others, dealt a decent set of cards, get on with their lives, there is a big section that is left behind. If comforting chemicals had never existed, noone would know these people or their unhappiness - but because they find temporary solace in drugs and alcohol, and the knock on effects of their habits are health and criminal consequences, whole care systems have been invoked to look after them. Yes, some of them Dalrymple will say, are indeed lazy blackguards - but not many - the rest are lost souls behind a smokescreen of chemicals, who we try to help and care for - and by looking no deeper than the smoke, his simplistic arguments disrespect them.

Part 1 E Modules have moved!

2007-07-31T12:24:00.000-07:00

Thanks to my friend Jo Betterton at the SMU, who writes:

The Part One e-modules have gone live on doctors.net.uk today

If people ask you should direct them to doctors.net.uk and everyone can complete them there, GP’s will go through the old route, nurses will go through the new nurse learning section and everyone else is now able to sign in through a new registration system they have built for us, this is signposted on the site and any problems will be dealt with by the doctors.net.uk helpline

If people go to the RCGP website they are directed to go to the Doctors.net.uk and can just click on the link that takes them into the Doctors.net.uk site where they log in and proceed as normal.

People are no longer able to register to start the e-modules on the RCGP website, but have until the end of September to complete them there if they have already started them.

Adult ADHD

2007-07-26T09:40:00.000-07:00

This is a diagnosis that I confess to being quite cynical about in the past, but the evidence and the scientific papers that suggest it is a real and treatable condition, are mounting up. I commend a Consensus Statement published by the chaps at BAP last year:

http://www.bap.org.uk/consensus/adult_ADHD.html

Try reading it as the detail is very interesting – and the checklist of signs and symptoms was fascinating, if only because I “Strongly Agreed” with all of them! (But if you know me that might not surprise you.) Particularly of note to me was that ADHD persists into adulthood in most cases, and continues to respond to stimulants, there is a strong inherited tendency, and untreated ADHD in childhood is strongly associated with the later use of illicit drugs and alcohol. So early detection might be one of those rare opportunities at preventing substance misuse, not to mention enhancing education and social functioning. So find out who your local specialists are, and if you suspect ADHD in a child (or an adult), get them assessed.

Cannabis, potency and Psychotic Illness

2007-07-22T22:21:00.000-07:00

This debate continues to rage, mostly in the tabloids but perhaps also in the new Labour Cabinet "Chill Out" rooms - and a search of the literature does seem confusing. Addiction (July 2005) published a report from Italy revealing that cannabis seizures over 20 years showed little change in THC concentration, and my chums at Transform whose bias they wear on their sleeves, say that american seizures have only revealed a doubling of potency in recent years (not a "30 fold" increase as some hysterical headline grabbers have claimed).

http://transform-drugs.blogspot.com/2007/04/cannabis-potency-update-ios-digs-in.html

I find my most reliable information source is our patients, and mine all seem to think that Skunk is a great deal stronger than block resin and weed was some years ago. Does that matter? well the association with psychotic illness has been made,

http://journals.cambridge.org/action/displayAbstract;jsessionid=F1921C7E09548430C6B105183E5B437D.tomcat1?fromPage=online&aid=141663

http://www.thelancet.com/journals/lancet

http://www.bris.ac.uk/news/2007/5554.html

and there are a number of disquieting parrallels with addictive practices in the past. For several thousand years the Indians of the Andes chewed Coca leaves with impunity and our Victorian forebears regarded a Laudanum habit as little more than a "weakness of character". But those who profit from supplying these things have learnt that greater concentrations of drug increase compulsion and demand, even tobacco companies enhance the nicotine content of cigarettes - if that were not the case, then Crack and Heroin would have no supply or demand - and we would all be happy with playing Snap, and not pressing buttons on Fruit machines all day. And greater compulsion and demand seem invariably to have harmful consequences.

We will see where this leads - but the lessons of the past seem to be going unheeded as usual.

NCIDU 2007

2007-07-20T23:15:00.000-07:00

The Exchange Supplies sponsored National Conference on Injecting Drug Use will this year be on Monday 15th & Tuesday 16th October at Glasgow's Radisson Hotel - you can find the conference programme here:
http://www.exchangesupplies.org/conferences/NCIDU/2007_NCIDU/programme.html

Plenary keynote topics will include: composition of illicit drugs: manufacture, adulterants, purity; developing our understanding of sharing, and how to reduce it; providing needle exchange to young people; insulin use by body-builders; pharmacy needle exchange; and
crack cocaine preparation and injection.

The Draft NEW DoH Guidance for Doctors working with Drug Users

2007-07-20T22:42:00.000-07:00

Comrades

I am sure that you have all been eagerly devouring the draft new National Guidelines and helpfully feeding back to the Politburo various tweaks and editions. For your edification I pass on my comments which are in no way expert, are completely my personal opinion and not those of the College, and treat the weighty tome with the sort of superficial dismissiveness which you have probably come to expect from me, but at least I have read it….

Overall I have to say that although I was prepared to hate it – in the main it is quite a good document, but at 204 pages, no way can this be called guidance – it is a text book that is comprehensive and draws upon current evidence as presented to NICE, and various other research from home and overseas.

The priorities are very clearly harm reduction – abstinence is noteworthy for being mentioned in the list of priorities, but only after all other avenues of harm reduction. Indeed reading the document you might well wonder if it is ever permissible to discharge a patient from treatment. I think that guidance that clearly steers us away from punitive practices and discourages the harm aggravation of discharge is absolutely necessary, but it should be balanced by guidance on situations (for instance serial non-attendance) where it is unsafe to continue prescribing.

Governance: you might expect (and you would be right) for a section on governance matters to be pretty turgid – but again it is necessary and welcome. I am dismayed by the number of colleagues who are put into positions where they are “over-extended” and neither supervised nor given proper appraisal by someone who understands their work One day something horrible will happen and the wretched doctor will have my blessing if he calls his employers/PCT into the Dock to stand alongside him – because they share the responsibility for his actions.

“Non Medical Prescribing” – a bit of an insult to nurses and pharmacists to call them “Non Medical” but we know what they mean – this is the way forward Comrades – it is high time that all these over paid Prima Donna doctors got their marching orders….............. oh hang on a minute….

Contingency Management – or “inducements”, are vogue at present – NICE saw the American evidence and were impressed, and that has come over into the draft guidance. Excuse me, but isn’t the USA the country where they deny cannabis smokers university grants, but do not extend the same punishment to rapists and armed robbers? Don’t they have more blacks in prison than are at liberty in the whole of Europe? And aren’t welfare payments roughly 40% of what we dish out in the UK? Call me old fashioned, but it is surely flawed to extrapolate that if American drug users attend appointments with their service because they are offered luncheon vouchers (as opposed to being sent down to San Quentin), that the good old British drug user will be similarly impressed? Maybe Contingency measures will be effective in Blighty, and maybe our paymasters will give us a load of money to support this, but I think that we need British evidence first.

As a document of “best practice” this is mostly pretty good in my view. At times it is very biased toward Specialist Service models and offers little to Primary Care with regard to low intervention/long term stable clients. There are a number of worthy although quite unrealistic statements eg: “Drug misusers in the criminal justice system should neither receive higher priority for their treatment, nor should their legal status deny them access to care equivalent to that available in the community.” I hope that the finished article will take account of the feedback that has been sent, and I hope that nothing else is sneaked in at the last minute……!

You can find the entire document and feedback forms by clicking this link:

http://www.nta.nhs.uk/areas/clinical_guidance/clinical_guidelines/cgl_update0607/consultation.aspx

and the latest NICE Guidance on Psychosocial interventions by clicking:

http://guidance.nice.org.uk/CG51

I've become a Blog

2007-07-20T10:06:00.000-07:00

It's a well known fact that to be a drug doctor, you've got to be "down with the kids" - and what better way to demonstrate that, than to host a Blog - a sort of self indulgent depository to commit one's thoughts to, where they can be cherished for posterity - and new members of the group can read the witterings passim of myself and others.

The plan is that in future I will post my ramblings here and simply send out an email announcement with a link, so that you can read them, or not, as you wish.