Alcohol at last

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

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

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

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?

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?

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

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

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?

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

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

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

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

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?

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

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?