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."