So you want me to prescribe dexamfetamine?

A post by guest blogger Graham Parsons, Lead Pharmacist, Turning Point.

What makes a “specialist” NMP in the modern day substance misuse service?

On the 4th November 2016 at the RCGP/SMMGP Managing Drug and Alcohol Problems in Primary Care conference, a group of Non-Medical Prescribers (NMPs) and doctors discussed what may be seen by some as a controversial topic – should NMPs become specialist prescribers within drug and alcohol services? Specialist prescribing will often be defined by the organisational formulary and prescribing policy but, in simple terms, it includes the prescribing of interventions such as dexamfetamine, slow release oral morphine (SROM) and injectable opioids. This article will briefly outline:

  • the background to non-medical prescribing
  • competency frameworks and
  • the debate during our workshop

My aim with this article is to start a discussion within drug and alcohol services following our workshop discussions over whether this is an area to explore rather than to develop a comprehensive plan for implementation.

Non-medical prescribing is now well established in the majority of drug and alcohol services. Its history dates back to 1992 when primary legislation was enacted to allow nurse prescribing. In 2003, pharmacists became the second profession to engage in this field following recommendations of the Second Crown Report in 1999. In 2012, access to controlled drugs for NMPs provided an opportunity for them to reach their full potential within our specialist environment of practice. There are currently around 19,000 nurse independent and supplementary prescribers[1] and around 3500 pharmacist independent and supplementary prescribers[2].

A framework for specialist prescribing developed by the Royal College of Psychiatry (RCPsych) and the Royal College of General Practitioners (RCGP) in 2012 provides guidance for doctors working in the drug and alcohol field[3]. It defines 3 levels of prescribers: specialist, intermediate and generalist. Developed around the two themes of supporting people to recover and clinical leadership it allows doctors, commissioners and organisations to clearly define the level of prescriber from their experience, qualifications and competencies. A national competency framework developed jointly with a number of national prescribing organisations (including the RCGP) and published by the Royal Pharmaceutical Society (RPS) provides a broader framework of competencies for prescribers[4] (figure one). Some organisations also have their own competency documents for drug and alcohol practitioners.

Figure One: The prescribing competency frameworkFigure One: The prescribing competency framework

The workshop

On the question on whether NMPs should be allowed to prescribe as specialists the majority verdict was “yes” (89%) provided the appropriate governance framework was in place to support this. However, there was a consensus that this should not be at the expense of the multidisciplinary skill mix. Nurses and Pharmacists have diversified this skill mix within the modern day service and the input of specialist doctors and addiction psychiatrists should not be lost as part of this process especially as part of a fiscal re-balancing of service provision. There was also a recognition that the individual NMP should decide, with their clinical supervisor, whether they should take on this role. Naturally any element of prescribing should be within the prescribers’ competency but there was recognition that NMPs should not be “forced” into such roles through “organisational pressure” which could destabilise both the individual NMP and the local drug and alcohol team.

The group considered that there should be no restriction to a formulary of drugs: the prescriber should define their own formulary through their competencies. This included the prescribing of diamorphine. Although legislation does not permit this currently for NMPs, the view was that some services may benefit from having an NMP who holds a licence to prescribe diamorphine. Does the political and clinical landscape support this? This is a full article in itself. Suffice to say the draft Clinical Guidelines does support the prescribing of diamorphine to those currently prescribed – the so-called “old-system” patients – and does not discount its use with the appropriate clinical governance in place locally i.e. supervised injectable treatment[5]. Perhaps 2017 could see an application to the Home Office for NMPs to hold licences for diamorphine prescribing?

There was a difference of opinion within the group on whether a specialist framework similar to CR173 discussed above is needed. Some NMPs considered that a framework would be a useful addition and allow a robust clinical governance process in an area where there may be some concerns and uncertainties from some individuals and professional groups. Others considered this “another document to complete” in a milieu of paperwork and processes. This cohort argued that an individual approach between the NMP and clinical supervisor which defined the competencies (from the RPS and RPsych documents) and experience needed was acceptable. One organisation currently uses the CR173 as a framework for NMPs as the “generic” nature of the guide supports this. Perhaps a blend of both approaches is the way forward? Again there remains some discussion within this area to find a route forward.

Finally the group discussed what NMPs required to become “specialist” prescribers within drug and alcohol services. Regular and good quality peer and clinical supervision with annual appraisals were regarded as prerequisites. Training should be individualised and outlined within the NMP’s CPD programme and supported by the organisation. While no specific time-frame was agreed on the experience of the NMP, it was agreed that a period of experience prescribing regularly in a service should be in place before prescribing in a specialist field. It was noted one organisation has a suggested minimum period of 3 years. A period of supervised prescribing with the specialist was also regarded as an important element of the transition to specialist prescribing.

In conclusion there does seem to be an appetite to explore “specialist” non-medical prescribing. It may already be the case that some services are engaged with this and I would be eager to hear how NMPs have engaged with this process. However, an appropriate clinical governance framework needs to be in place to support this which a) protects the NMP b) protects the service user and c) gives confidence to colleagues and commissioners. There may also be an opportunity to take the final step and cross the final frontier into diamorphine prescribing.

Let the debate begin…

– Graham Parsons, Lead Pharmacist, Turning Point

Contact: graham.parsons@turning-point.co.uk

 

References

[1] RCN Fact Sheet (2012) Nurse Prescribing in the UK. Available at https://www2.rcn.org.uk/__data/assets/pdf_file/0008/443627/Nurse_Prescribing_in_the_UK_-_RCN_Factsheet.pdf (accessed 22/01/2017)

[2] RPS (2017) Pharmacist prescribers. Available at http://www.rpharms.com/home/home.asp (accessed 22/01/2017)

[3] RCPsych (2012) CR173 Delivering quality care for drug and alcohol users: the roles and competencies of doctors. Available at http://www.rcpsych.ac.uk/files/pdfversion/CR173.pdf (accessed 22/01/2017)

[4] RPS (2016) A Competency Framework for all Prescribers. Available at http://www.rpharms.com/support-pdfs/prescribing-competency-framework.pdf (accessed 22/01/2017)

[5] DH (2016) Drug misuse and dependence: UK guidelines on clinical management – Consultation on updated draft 2016. Available at http://www.nta.nhs.uk/uploads/cg-2016-consultation-draft.pdf (accessed 22/01/2016)

Underdiagnosed, undertreated and on the rise – getting to grips with alcohol-related brain damage (ARBD)

Guest blogger Andrew Misell, Director of Alcohol Concern Cymru, explains what Alcohol Concern has been doing in recent years to promote better understanding of alcohol-related brain damage (ARBD) and better support for people with the condition and their carers.

“Alcohol was mentioned as a possible cause five days before he died. The consultant told me that the dementia was most likely caused by alcohol.”

“I looked up my symptoms and thought I may even have Parkinson’s Disease. I didn’t even know that alcohol-related brain damage existed until somebody said I had it”

Every since Karl Wernicke and Sergei Korsakoff, in the 1880s, noticed symptoms of confusion and confabulation in their patients, it’s been clear that long-term heavy drinking can have a devastating effect on the human brain. But somehow, 130 years later, it seems that the message about alcohol-related brain damage (ARBD) is still getting lost in the system. The two comments above are sadly typical of many people’s experiences.

General medical wards, care homes and dementia facilities are still hosting many people who’d be much better off receiving specialist rehabilitation that recognises that alcohol dependency is the root-cause of their illness. Many conscientious professionals realise that they’re seeing people with ARBD week-in week-out, but don’t feel that they have the expertise to help them, nor anywhere suitable to refer them on to. The tragedy of all this is that with the right help, someone with ARBD can recover some or all of their mental and physical capacity.

We’re under no illusions. We know that a small charity like Alcohol Concern is not going to transform ARBD services overnight. What we thought we could do was plug some of the information gaps that leave so many families, cares and professionals feeling so powerless. With that in mind, and with a grant from the Garfield Weston Foundation, we have created an online hub of ARBD information, and delivered ARBD training to frontline staff around the country.

The hub includes:

  • A series of easy-to-read factsheets on causes and symptoms, diagnosis, treatment and support
  • Legal factsheets on the routes it may be appropriate to take if someone with ARBD lacks capacity to make major decisions for themselves: advance decision making, lasting power of attorney, and use of Mental Capacity Act
  • An in-depth support manual for families and carers
  • A quick guide to the condition for professionals.

We’ve delivered ARBD training to more than 300 frontline staff so far, attracting practitioners from a range of sectors. Our aims have been to enable learners to:

  • Define ARBD, its prevalence and impact
  • Identify risk factors and how risk can be reduced
  • Recognise signs and symptoms
  • Explore the stages of rehabilitation
  • Use simple approaches to improve outcomes
  • Signpost patients and their carers to further support.

We’re proud of what we’ve managed to achieve so far, but we also know it’s a drop in the ocean. The issue of ARBD isn’t going away any time soon. If anything, if we are able to improve recognition of the condition, there’ll even more work to do to support those patients who were previously undiagnosed and untreated. International post mortem studies have found signs of Wernicke-Korsakoff’s Syndrome in around 1.5% of brains – a figure that would suggest nearly 1 million people in the UK have some form of the condition. Even if that figure’s wide of the mark, we know that there are a lot of people out there living with ARBD without anyone realising what’s making them the way they are; and as the Scottish Government warned back in 2004, the age at which people present with ARBD symptoms is getting lower.

Given all this, we’re keen to do more:

  • Develop our hub into a real online forum for ARBD information exchange and learning
  • Develop our training: we have initially provided one-day courses but many participants have said that they need more time than that to get to grips with this complex and challenging topic.

– Andrew Misell, Cyfarwyddwr / Director, Alcohol Concern Cymru

If you’re interested in working with us to improve the recognition and support of ARBD in primary care, or if you’d like to know more about our training offer, please contact Andrew Misell at Alcohol Concern on 029 20226746 or e-mail arbd@alcoholconcern.org.uk.

To visit the online ARBD hub and download our factsheets, go to: www.alcoholconcern.org.uk/arbd

 

 

 

A name not a number

Dr Steve Brinksman writes the regular “Post-its from Practice” articles for Drink & Drugs News (DDN) Magazine. The most recent Post-it (Nov-2016) is a guest post-it written by Judith Yates and appears below with kind permission from DDN.

Post-it Past Practice – from the RCGP Conference 2016
A guest post-it by Judith Yates

I first met David in the 1980s when, as a small child, his mother kept him away from school all too often. She struggled to cope with life. By the end of the 1990s, in his early twenties, David was a regular attendee at my surgery, prescribed methadone and supported by my drug worker.

One night he banged on the back door of the surgery after 7pm when we were supposed to be closed and trying to pack up and go home. Our gentle hearted nurse Angela opened the door to ask what he needed and stepped back as he staggered in, fell to the floor, stopped breathing and turned rapidly blue. My quick-witted partner ran to the emergency cupboard and dug out our newly acquired naloxone kit. Naloxone is the antidote to opiate overdose and David was breathing again, although still groggy when the ambulance arrived.

When he returned to my surgery for his routine appointment the following Tuesday he was surprised to be met joyfully by the reception staff who had thought he might have died. On waking in the hospital he had had no idea how he got there, how close he had been to death, nor the role played by the surgery team. His was the first life I had known to be saved by naloxone.

It was therefore a shock two weeks ago, to see David’s name in the stark “drug related death” summary I was reading on a clear sunny day in Birmingham. I had trodden a familiar path to our local Coroner’s Office to review the thick ring-bind folder containing reports of all inquests held in the city during 2016, as part of the preparation for our newly re-formed “Drug Related Death (DRD) Local Inquiry Group”.

It seems that David had no longer been in treatment at the time of his death as only heroin had been found on toxicology. I suppose there was nobody around to administer naloxone on this occasion.

This reviewing of the inquest reports is a miserable job, not only because beneath the terse language of the certificates lie the shocking stories leading to these sudden and unexpected deaths, but also because having been a GP in the area for over 30 years, I have known many of the people who have now come to the end of their lives in ways which might have been avoidable. It is always especially upsetting to find that one of my old patients has died in this way.

Last week, standing at the podium to address the audience at the 21st RCGP/SMMGP “Managing Drink and Drugs problems in Primary Care” conference, I felt the warm glow of a room full of people who have been working together for all of the 21 years and more, but my subject matter, a review of drug related deaths in Birmingham, replaced this with an icy chill and a feeling that we must be missing something. I thought of David and the other people I have known who have died suddenly and unexpectedly in this way.

We have all read the headlines telling us that heroin related deaths have more than doubled in England and Wales, between 2012 and 2015 (Ref 1). Prof David Nutt speaking at the same conference asked the question “Why are we collecting all these statistics if we aren’t doing anything about them?” It is only by looking behind the statistics that we can have a chance of understanding what may be the causes and more importantly, what solutions can be found.

It is shocking that in many parts of the country, as in my city, drug related death inquiry groups fell victim to the financial cuts in services, and often no longer meet at all. As a result, nobody has been investigating the deaths of people not actually engaged with treatment services at the time of their death. The latest analysis by PHE shows that more than half of people who die in this way have never been involved with drug treatment services, at least since NDTMS records began seven years ago, and more than 70% were not engaged with treatment services at the time when they died (Ref 2).

We need to learn from each of these tragedies and add to the frequently simple and usually not even expensive actions, which we already know from international evidence contribute to reducing future deaths. These include: low threshold prescribing (and welcoming rapid re-engagement for those who drop out), supervised consumption facilities offering cups of tea, conversation and a safe hygienic place to inject for the most vulnerable who are not ready or able to come into treatment, and wide access to take-home-naloxone wherever it might be used to save a life.

David was only in his late thirties when he died, an increasingly common age for people to suffer accidental overdose. He was of course more at risk because of his age and history, because he had fallen out of treatment, and because he had a history of non-lethal overdose in the past. His death almost certainly could have been avoided.

We have powerful examples of effective analysis and action, for example from the airline industry, the maternal deaths confidential inquiry groups, and the investigations into every road traffic accident death, all of which have found ways to prevent avoidable deaths.

In 2009 Airline pilot Captain Sullenberger astonished the world when he made an emergency landing of his plane on the Hudson River, saving every life on board. When asked how he knew what to do, he said, “Everything we know in aviation, every rule in the rulebook, every procedure we have, we know because someone somewhere died. We cannot have the moral failure of forgetting these lessons and have to relearn them” (Ref 3).

Local inquiry groups are needed now more than ever to look at every fatality and ideally at the near misses as well, to inform our treatment efforts and perhaps even more powerfully to inform people who use drugs how to keep themselves alive and safe into the future.

– Judith Yates

References

1. www.ons.gov.uk
2. www.nta.nhs.uk
3. Quoted in “Black Box Thinking” by Matthew Syed, 2015

Note: Previous Post-its from Practice can be found in the Resource Library on the main SMMGP web site.

Favourite patients, shame and redemption (it takes time)

Jonathon Tomlinson, an “ordinary GP” in Hackney, writes in a recent blog post on “A Better NHS” about caring for patients who are ashamed. He writes against the backdrop of two books, one fictional, one fact, about dealing with shame brought upon by childhood trauma.

We are very grateful to @mellojonny (on Twitter) for granting us permission to reproduce extracts of his article on our website, and for giving us the opportunity to reflect for a moment on what brings these favourite patients to our doors, and why there is often no “quick fix” when they do seek help:

Extract from Shame and Redemption, a blog post by Jonathon Tomlinson:

“Almost every GP I know is overwhelmed with caring for adults who suffer from shame, many of whom have been abused. They present with chronic pain, medically unexplained symptoms, anxiety and OCD, paranoia, fatigue and drug and alcohol addiction. We label them with medical syndromes, psycho-somatic, psychiatric and personality disorders. We refer them for medical investigations, specialist opinions, psychiatric assessments and psychotherapy. They leave us shattered, demoralised, burned out. They are chaotic, exhausting, and also among our most loved patients.

I’ve recently been doing work with old and young GPs about our favourite patients. For young doctors, favourite patients are friendly, cooperative, honest, and grateful. They present with symptoms that lead to a diagnosis and a cure or failing that, a good death. Gratification is quick. Dreaded patients are the opposite of all these things.

I asked four experienced GP trainers each to describe one their favourite patients to a room full of trainees. The patients they described were hard to form relationships with, took time and hard work to get to know, they were argumentative, dishonest, chaotic and disruptive, unwilling partners in care. For some it took years, decades even to reach a point of mutual trust and respect, but eventually they were rewarded with the kinds of relationships that can only come with going through and overcoming hardship together.

Evidence about resilience of doctors who work in challenging areas concluded that they were sustained by a deep appreciation and respect for the patients they cared for. Gratification with challenging patients comes slowly. Those who frustrate us most will eventually be the ones that sustain us, but only if we preserve the continuity of care that we are in grave danger of losing in an increasingly transactional NHS.”

Read the complete article on:
https://abetternhs.net/2016/11/21/shame-and-redemption

More reading:

A qualitative exploration of favorite patients in primary care. (Lee et al) 2016
https://www.ncbi.nlm.nih.gov/pubmed/27378080

The CBT Book Club (A psychoeducational triage model for health behaviour change)

Guest blogger Paul Russell writes about the success that he has had with “The CBT Book Club (A psychoeducational triage model for health behaviour change)”.

Paul has worked in substance misuse services for over 20 years, including developing cognitive behavioural therapy (CBT) and motivational interviewing (MI) programmes for residential services and in primary care over many years. He is deeply committed to developing an evidence based approach and helping make “talking therapies” more accessible and relevant.

The CBT Book Club for Adults was introduced initially as a triage model for people who were waiting to receive psychological therapy within IAPT, skilling people up over 12 weeks before they attend one-to-one counselling or stepped services.

The aims of the CBT Book Club are to:

  • Improve access to IAPT and reduce waiting times;
  • Introduce the CBT well-being model for depression and mood management;
  • Introduce anxiety coping skills and resilience training;
  • Provide an introduction to Health behaviour change model for patients concerned about e.g. weight management;
  • Engage patients with problematic alcohol/substance use not requiring Specialist services.

The CBT Book Club for Adults has been run in primary care for over twelve months, and was initially a natural follow on from the “Books on Prescription” scheme with 960 people attending through the year, with a retention rate of over 70% during each 3 month club with over 50% of users self-reporting they had met their initial goals and were feeling better than when they had started.

People presented with a range of issues, including ongoing depression, anxiety disorders, substance misuse and issues regarding weight management. Patients were mostly people who would have often been traditionally referred to specialist services. The intention is to introduce a well-being model to patients and thereby support them to develop resilience and coping strategies around a number of concerns.

We found this approach – a generic psychoeducational model, supporting people not to define themselves by any one particular issue and with a non-judgemental, nondirective approach – served to destigmatise attendance and engagement.

The model is based on a psychoeducational CBT approach and follows 12 chapters each covering a different topic such as: “Introduction to the CBT Model, Understanding Anxiety, Managing Depression, Developing Resilience and Understanding Behaviour Change”, with sub topics for example “Assertiveness, Managing Conflict, Understanding Stress”. Each week ends with set assignments and exercises and is based on a systemic skill based approach, the intention being that the patient is receiving support and developing coping strategies as they move through the waiting list to join formal IAPT services.

The Book Club model was chosen as it is already a well-known familiar format, which normalises and makes group therapy less daunting and off putting to people.

People are not asked to qualify why they want to attend, except wanting to do more of something and less of something else (having to identify a particular group to attend  was found to be a common barrier for many people).

A psychoeducational therapy approach was chosen as opposed to a process one i.e.  talking and  sharing which we found can generate a lot of resistance for people and can often result in a high drop-out rate,  The CBT Book club has been described as “group therapy for people who don’t want to do group therapy”. Many patients have gone on to form their own “book clubs” or discussion groups and spin-off groups have been formed such as:

CBT Book club for Teenagers
An abridged CBT model with age specific topics.

CBT Book club for Children
An abridged CBT model for younger children with age specific topics.

– Paul Russel

NMPs in Substance Misuse Services – An increasingly visible force

Posted by guest blogger Rosie Mundt-Leach, Head of Nursing for Addictions South London and Maudsley NHS and Membership Secretary, National Substance Misuse Non-Medical Prescribing Forum (NSMNMPF)

Non-Medical Prescribers (NMPs) have become an increasingly visible force within the substance misuse treatment staff mix. Although the majority of NMPs are nurses, there are also a significant number of specialist pharmacists who have taken on the prescribing role. Until 2012 NMPs were subject to legal restrictions in their practice and were only able to continue prescribing controlled drugs for the treatment of substance misuse and could not initiate new treatment programmes. The law changed in 2012 and now (with the exception of highly specialised treatments such as diamorphine) NMPs can play a full role in prescribing treatments across all addiction care pathways.

The commercial diversification of the substance misuse sector has enabled NMPs to find roles in every type of provider organisation. The Forum has members employed in the NHS, third sector, community interest companies and the independent sector. NMPs are working in community pharmacies, acute hospital liaison, prisons, community drug and alcohol teams, in-patient detox/rehab and primary care.

The widening of the scope of the NMP role has contributed to the increasing popularity of Non-medical prescribing, but arguably the main factor driving the growth of numbers is the relatively lower cost of employing NMPs compared to doctors.

Public Health England guidelines – Non-medical prescribing in the management of substance misuse – looks at the practicalities of having NMPs working in services and some of the strategic issues that commissioners and managers need to consider when training or employing NMPs:

http://www.nta.nhs.uk/uploads/nmp-in-the-management-of-substance-misuse.pdf

In my role as Head of Nursing for South London and Maudsley NHS Addictions services, I see the benefit of having NMPs every day. We have NMPs in our shared care services and CDATs and they are able to provide a comprehensive treatment programme for patients at all stages of treatment. We now encourage as many eligible staff as possible to undertake the training and find that those who do, increase in their confidence and enjoy the additional responsibility. The services definitely benefit from having an increased flexibility in staffing structures. They certainly haven’t replaced doctors but the increased prescribing workforce means we are able to target resources where they are most needed to meet the needs of people in treatment.

Qualified and trainee NMPs have a free forum for professional education and support, namely the National Substance Misuse Non-Medical Prescribing Forum, which has its own website:

http://www.nmpsm.org/

There are members in England, Scotland, Wales and Northern Ireland and associates in Eire.

– Rosie Mundt-Leach, NSMNMPF Membership Secretary

Return of the “Post Code Lottery”

Dr Steve Brinksman writes the regular “Post-its from Practice” articles for Drink & Drugs News (DDN) Magazine. The most recent Post-it (Feb-2016) appears below with kind permission from DDN.

My practice has long had a reputation in Birmingham for working with people who use drugs and alcohol, and who are much more complex than those seen in most shared care practices. We were recently approached by the newly commissioned service to see if we would treat a man whom – for a variety of reasons – wasn’t engaging with the main drug service. This has happened before and no doubt will again; as whilst a commissioned service is designed to deliver a good level of service to the majority of its clients, by virtue of commissioning arrangements it has to work within defined parameters.

So what happens when a client falls out with a service, or a service falls out with a client! It is a fact of life that we don’t see eye to eye with everyone and sometimes irreconcilable differences develop, in my experience within drug and alcohol treatment this is frequently due to intransigence in both parties. However the service user can’t fall back on or blame “procedures”, “staff shortages” or “we aren’t commissioned to do that” statements!

Previously when drug and alcohol treatment was part of health services, a service user would usually be placed in an alternative treatment system bearing in mind that access to NHS treatments should be fair, equitable and available to all. However since Public Health has moved into the realm of local government this seems to have changed. All councils will commission drug and alcohol services but I suspect they are less willing to fund the “square pegs” that may need to be sent to a different service. I have come across a number of clients now who simply fall through the cracks and due to a breakdown in the relationship with the “only show in town” are outside of treatment and despite wanting help, they can no longer access it.

We are fortunate in Birmingham to have a number of highly skilled GP practices as well as the central service for drug and alcohol treatment, so it is usually possible to accommodate most clients who have a problem with one provider, in an alternative service – albeit that a client may need to embrace change within themselves too for the arrangement to work.

I worry about what may happen elsewhere in the country if this diversity isn’t available, how many people are excluded from their local treatment provider [for whatever reason] and simply not able to find an alternative? And what should we do about it?

– Dr Steve Brinksman
Birmingham GP, SMMGP Clinical Director, RCGP Regional Lead in Substance Misuse for the West Midlands

Note: Previous Post-its from Practice can be found in the Resource Library on the main SMMGP web site.

Ask the right question!

Dr Steve Brinksman writes the regular “Post-its from Practice” articles for Drink & Drugs News (DDN) Magazine. The most recent Post-it (Sep-2015) appears below with kind permission from DDN.

Marco rarely came to the surgery; he was a 44 year old restaurant owner with two young children but on a routine screen had been picked up as having high blood pressure. He had been given advice to lose a little weight and exercise more but this made no significant difference to his blood pressure. He was started on an anti-hypertensive and his blood pressure improved but 12 months later it was up again and as he was adamant he was taking his medication every day, a second drug was added in. Three months after this he had come back to see one of our registrars and she had noticed his blood pressure was again poorly controlled. She decided to discuss this with me as part of her learning portfolio.

His notes showed he had been overweight but his BMI (Body Mass Index) was now 26 so this was unlikely to be a significant factor, he had stopped smoking when his first child was born 7 years earlier, his renal function was normal and no significant past medical history was recorded. I asked her if he drank alcohol. “I’m not sure,” she said and indeed nothing was recorded in his notes about alcohol consumption. I explained that excessive alcohol use was a major factor for hypertension and cardiovascular disease a fact unknown to many patients – and quite a few medics as well!

He was due for review the following week and told her he drank a bottle of red wine every day, as it was good for his heart! She explained to him about the effect alcohol has on high blood pressure and cardiovascular disease and he had been shocked by this. He decided to try and cut his alcohol down rather than take a third medication. His blood pressure improved over the next few weeks and it was possible to stop one of his tablets.

I was the next person to see him and this time his blood pressure was within the normal limits albeit that he was still taking a single drug to control his blood pressure. He told me he had reduced his alcohol to half a bottle one night during the week and half a bottle each day over the weekend. I wonder how many patients have physical and mental health problems related to their drug or alcohol use that pass unnoticed because a health professional doesn’t ask.

SMMGP have launched an introductory online training module about the Community Management of Alcohol Use Disorders which can be completed free of charge on the SMMGP e-Learning website.

– Dr Steve Brinksman
Birmingham GP, SMMGP Clinical Director, RCGP Regional Lead in Substance Misuse for the West Midlands

Note: Previous Post-its from Practice can be found in the Resource Library on the main SMMGP web site.

Naloxone – what the new legislation changes mean

Kate Halliday, SMMGP Programme Lead, discusses the recent legislation changes which make naloxone more readily available for those that need it.

Naloxone counteracts the effects of opioid overdose and while its distribution to current and past drug users has been encouraged in England there has been a patchy uptake of the drug. Many of us have been waiting for the 1st October 2015 when the Human Medicines Act legislation changes came into force to give more options for the distribution of naloxone (see explanatory memorandum from the Medicines and Healthcare products Regulatory Agency). Recent statistics showing a large increase in drug related deaths has only sharpened the desire to increase accessibility of naloxone for opioid users and those in contact with them.

Why has the legislation changed?

Prior to 1st October 2015 naloxone was supplied under prescription, often by patient group directions (PGD) by nurses pharmacists and doctors within drug treatment agencies. Naloxone could be supplied to those:

  • currently using illicit opiates, such as heroin
  • receiving opioid substitution therapy
  • leaving prison with a history of opioid use
  • who had previously used opiate drugs (to protect in the event of relapse)
  • With the agreement of the individual at risk it could also be prescribed to, family members friends and peers.

Whilst this system has led to a great deal of naloxone being distributed in many areas there is a recognition that there were also barriers for many people who were willing and likely to use naloxone from receiving it. For example hostel managers, organisations that provide services for people who are in contact with drug users (e.g. homelessness projects) and family members and carers who for a variety of reasons may not have gained consent from their loved ones could not access naloxone despite the fact that they were clearly in situations which they may use the medication to save a life. There were also structural problems in many services which acted as barriers to dispensing naloxone: some areas had not yet got PGDs in place, and where they did exist the pressure was often on precious nurse time to dispense the medication to individuals, and systems were not always as responsive as they could have been.

What do the changes mean?

There are two main changes the new legislation has brought about. Firstly, anybody employed by agencies providing drug treatment – and not just nurses/doctors – can supply naloxone meaning that it can be distributed by a much wider group of people working in services. Secondly, naloxone can be supplied by agencies providing drug treatment to anyone in the course of lawful drug treatment services where required for the purpose of saving life in an emergency. In other words, named hostel managers and managers of projects which drug users are likely to use, and family, friends and carers of drug users may now have access to naloxone where it is assessed appropriate.

What needs to be in place to implement the changes?

If it has not been done so already, get a policy agreed locally that reflects the changes in legislation. We are grateful to Inclusion for letting us share an example of what a policy can look like that can be adapted to local requirements.

For many drug services the governance will come via the systems that oversee the overall clinical governance for medical services – but this does not have to be the case. The governance can go through social care/voluntary agency structures as long as the agency is providing drug treatment to individuals – consultation with clinical/medical teams should be part of this process.

Don’t forget that SMMGP’s free e-learning module Naloxone Saves Lives can support local training programmes that are set up.

If you do not have one already, set up a naloxone action group to coordinate the implementation across your area. Have you considered all the hostels and agencies in your area who are in contact with drug users that may benefit from having naloxone? Get a strategy for reaching carers in your area who may be interested in having naloxone. Is there a way you can improve naloxone distribution to hard-to-reach groups in your area?

These are exciting times for those of us who have been trying to increase distribution of naloxone to at risk groups; many of the barriers to distributing the medication have now fallen away. It’s up to us to make this legislation work!

Further reading and information

Public Health England have provided information about the effects of the change in legislation.

– Kate Halliday
SMMGP Programme Lead

“Effort Street & Recovery Road” – Recovery Month Reflections

Dr Steve Brinksman, SMMGP Clinical Director, reflects on International Recovery Month in a post inspired by walking down Effort Street and Recovery Street in London.

Effort StreetSeptember is International Recovery Month and so there are many events around the UK this month which celebrate the gains people have made in recovering from addiction to drugs and alcohol.

Recovery is everywhere and in primary care we have many “recovery events” as we celebrate each step in the right drection as a successful one on the road to better health.

Being fortunate to work with people who use drugs and alcohol as a GP, I see recovery in all its many guises on any given week.

I see it in an abscess that has healed, when I know someone has picked up clean needles, or another has started treatment and their family member – who also comes to see me – reports feeling less anxious about their drinking.

Recovery StreetAnd when a patient now stable on OST is able to keep his job, whilst someone else has experienced the amazing “C change” of testing free of the hepatitus virus, they are making their way along Effort Street on the way to Recovery Street.

My drug and alcohol patients are rarely discharged. Rather in the brave new world of self-efficacy where patients are no longer passive recipients of treatment, we continue to work together as we build a long-term relationship and achieve ongoing improvements in their health and wellbeing. Happy Recovery Month.

– Dr Steve Brinksman
Birmingham GP, SMMGP Clinical Director, RCGP Regional Lead in Substance Misuse for the West Midlands