Scandalous Sacking of David Nutt

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

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?

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

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

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?

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

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.

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.....

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

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?

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

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

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?

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."

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)