Patient Going Abroad?

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

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!

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!

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

...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

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!

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

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

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!

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!

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

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.