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

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!

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:

Key Messages

Clinical Guidelines

Nice Guidance

Implementation

Weights and Measures

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

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

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

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