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

 

 

 

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

Fight for the future of shared care

At the RCGP 20th National alcohol and drugs conference last week there was evidence that a number of shared care schemes are being decommissioned following changes in tenders during the process of re-commissioning services. Guest blogger Paul Roberts suggests we need to be ahead of the game when it comes to preserving shared care services.

It was shocking to hear at the 20th RCGP National Drug and Alcohol Conference of the many areas in the UK where ill-considered commissioning decisions are dismantling shared care services at the very moment that Simon Stevens’ five year forward view is demanding more integration. A conference position statement is part of the solution, but other strategies are needed to counter the prejudices of maverick commissioners. Sadly commissioning is often not as sophisticated as one would want and it is easy to interpret ignorance as enemy action. Most of us feel “got at” at least some of the time but we have to strive to avoid seeing ourselves as passive victims. There are opportunities to avoid further disasters. The value of these contracts is large so they are going to be tendered under current legislation; we cannot change this given the last election result, we have to play by the commercial rules.

This is the start of a list how to play an active role in the commissioning of drug and alcohol services in your area. This is not exhaustive, and I would encourage you to add anything I have missed in the comments section:

Be aware of the commissioning plans for drug and alcohol services in your area. Contracts tend to come up every 3-5 years. Sometimes contracts get extended because of lack of local appetite or resource to support re-tendering.

  • Whilst Clinical Commissioning Groups (CCGs) may not be leading on commissioning of drug and alcohol services they will be aware of them and should have an influence. Pester your responsible officer to keep you informed of the timetable for any re-commissioning so that a stealth approach is not possible.
  • Commissioning specifications should go out to consultation; let the commissioning lead know you are interested and would like to contribute to the development of the specification.
  • Spell out the benefits of shared care to everyone involved in writing the specification. Do this specifically in terms of overall care for long term conditions and normalising individuals’ treatment. Commissioners are mostly completely fixated on avoiding unplanned admissions and stopping local people going to A&E. They probably haven’t stopped to think how shared care contributes to these goals.
  • Help your patients help you to help them. There has to be service user involvement in the process. Speak to the patient representative on the CCG board. Get them to come and talk to some of your patients. If you don’t do this then it is likely that the only view that is obtained will be from clients attending a community clinic provided by the incumbent provider. It is assumed that the commissioning specification will contain lines about being sensitive to the needs of local communities and to be building on existing good practice (because they always do). Once the commissioning process starts you have options, but you have to act quickly (so it is best to have thought about this, and have had discussions before).
  • It is possible for a group of GPs to tender to deliver an entire drug and alcohol service? This is a step that may be beyond most of us.
  • Shared care requires wrap around services; who are the agencies providing this now? Are they any good? Are they bidding?
  • Identify who the likely bidders are going to be; who would you want to work with?
  • Approach them early, explain that you want to sustain shared care and that you want it in the bid. You are unlikely to be rebuffed since a bidder who has a demonstrated, worked out relationship with primary care is likely to appear better at interview. There are a couple of likely outcomes:
    1. Bidder welcomes you with open arms and invites you and your colleagues to form a consortium bid (this has to be decided at a very early stage since NHS procurement traditionally goes through a two stage process). The first stage requires potential bidders to identify themselves in a Pre-Qualification Questionnaire stage (PQQ) during which they are assessed for viability. If a consortium has not been assessed suitable via a PQQ then it will not be allowed to tender.
    2. Bidder indicates that they do not want to form a consortium, but is keen to work with you as a group of subcontractors. This will require commercial negotiation. What are you signing up to do for how many clients/patients? What level of support are you going to get in your surgeries, who is going to be responsible for what? A commissioner is going to want to see some sort of outline contract as part of the tender submission along with a governance structure indicating lines of responsibility. In some areas shared care was funded by a local enhanced service agreement. Financial planning on both sides requires understanding about the proposed continuation (or not) of such schemes. This is the sort of undertaking that a local GP federation may well be in a position to support, if it is brought to their attention.

    Assuming one gets to interview then ensure that you are well prepared.

  • Commissioners want a guarantee that their future service provider has the capacity to do what they say they are going to do in a safe manner.
  • Commissioners will want to deal with one agency not 20 practices.
  • Governance is very important.
  • Use the opportunity to explain, once again, how shared care fits into the wider current NHS England agenda. It is a shining exemplar for multiagency working. If it is done well the relationships developed with housing, social care and other third sector organisations can be positively exploited to provide similar approaches for other marginalised groups. The Five year forward view paper talks of multi-speciality community providers as being a desired end point. At its best shared care is this in embryonic form and it needs to be sold as such.

– Paul Roberts, GP

The importance of user led advocacy

A post by guest blogger Sapphire from The Alliance…

My experiences in treatment have been long and varied. When I started in treatment in the mid 90’s, it was all very different. I was put on a dose of 35mg methadone, as being young, and a girl to boot (women were routinely put on lower doses than men, regardless of whether their substance use was larger or more chronic). The man I was living with was put on 50mg, despite him using the exact same amount of drugs as I, and having a not dissimilar build.

35mg was nowhere near enough to keep me well for 12 hours, let alone 24. Needless to say that led me to continuing my illicit heroin use. At the service I persistently asked for increases, only to be declined.

As I was working at the time, the prescribing service felt I would be better in shared care as there was more opportunity to see the prescriber out of office hours, so I went to my GP surgery for my prescription. The GP was pretty good, and did increase my dose some, although at this time I did not realise the importance of optimal dosing, and thought that the ‘right’ dose was just the lowest amount that stopped you being sick for most of the day!

The GP was a pretty good prescriber, and was sympathetic to my needs and was well read on the evidence and latest innovations in the substance use field. After more discussion with her, we increased my dose further, to 100mg, in the hope that it would be the right dose for me. At that time, the late 90’s, having a dose of 100mg was seen as quite high, and many people were surprised.

During this time, I was still using most of the time, but instead of using heroin which would show up on a drug screen (these were the bad old days of 3 positive drug screens and you were out on your ear) I was buying illicit methadone and using that on top. I got into a routine of taking about 200mg a day, and was able to function, work and was quite comfortable.

After some upheaval in my personal life, I ended up with an additional addiction to crack cocaine, which led to me losing my job, my home and everything else. This was the lowest point in my life: I was homeless, turning to illegal means to support my habit, and my mental health was suffering very badly as a result of all the crack use.

It got to the point where the crack took its toll so much that I was hospitalised for mental health issues. The hospital that I was sent to had a self contained unit used to treat substance use disorders, so they decided that would be the best place to put me whilst they decided what I needed.

During my time there, I was stabilised on a dose of methadone where I didn’t have to resort to illicit means to top it up. This was really a pivotal moment for me, getting optimally dosed on methadone. I was given 220mg a day, and for the first time since being addicted to opiates, I felt that things were getting better, and it was possible to get my life back. It was a very good feeling, and looking back, I am very grateful to that doctor who realised that most of my problems stemmed from not being optimally dosed with methadone.

After being in the unit for 2 weeks and detoxing from the crack and stabilising on methadone things certainly got a lot better for me. I was able to move into a new home with my husband, go back to college and generally get on with life.

As when my husband and I moved in together we had moved to a different part of the country that meant transferring to a different treatment service, which was very problematic. Not only was the transfer difficult with the new service taking ages to generate the new prescriptions even though they had 8 weeks notice to do so, they were also horrified by my dose. I don’t think they had anyone on anywhere near the dose I was on (the average dose was around 60mg) and they could not understand that I was not getting ‘high’ or over sedated from my dose.

This is what led me to the Alliance. As I started having more issues with my new provider, I began to realise that I needed to learn how to advocate for myself, and learn what the guidelines were around such matters are dose levels, time in treatment and reductions.

Once I had been at the new service for about a year, they started mentioning to me that there was a new government initiative, and that I must start reducing, as they were not allowed to keep people on the same dose for as long as I had been.

I spoke with the Alliance, and found out that although there had been some changes in the government drug treatment policy since the Coalition had come into power, there was nothing that said patients could, or should, be forced out of treatment.

The members of the Alliance provided support, and advised me of the guidelines I might need to quote to my service provider, such as the Orange Book[1]. The support was invaluable, as I felt very alone in the matter, as the very people supposedly supporting me in my substance use issues were the ones causing me problems in that area.

The pressure was so intense, and every time I went to collect a prescription I was terrified that it would have been reduced without my say so. It was amazing to have the support and advice from the members of the Alliance who knew where I was coming from, and from other people that had been in the same situation.

There was also pressure applied around the ECG and prolonged QTc interval issue. I was made to have 10’s of (in my opinion) needless ECGs and told that I did have a prolonged QT interval.

The Alliance pointed me to the Orange Book, where I learned that I did not in fact have a prolonged QTc interval, and that either someone at my service was misinformed, or they were using patients’ lack of knowledge around this issue as a means to talk them into agreeing to a reduction they didn’t really want.

After being advised by the Alliance to start by making a formal complaint, and quoting the Orange Book and NICE guidelines stating that coerced or enforced reductions against the wishes of the patient are unadvisable as they are unlikely to be successful and put the patient at risk of relapse together with the levels of QTc interval that are acceptable for methadone prescribing, the service conceded that I did not in fact have a prolonged QTc interval, and did not push the reduction matter any further.

It was very disappointing to feel that my service were not really interested in my best interests, or what I wanted, seemingly only in how many people they could get out of treatment.

However, although my service now were not pushing me into something I didn’t want, and that wasn’t in my best interests, I knew that my service, and others across the country were doing the same thing to countless other patients; this is what led me to take a more active role in the Alliance.

In this day and age, it is very important to have a user led advocacy organisation, as sometimes it’s very difficult to understand and empathise with exactly what a drug user or person in recovery is going through.

Some doctors and treatment staff are excellent and do a very good job, but in some cases pressure from local commissioners, financial pressure and the introduction of payment by results mean that some staff are not always incentivised to do the best thing for the patient.

In my own case, my service was put up for tender and taken over by a third sector provider late last year, and I have to admit I was very worried. At the Alliance we have heard some terrible accounts, many of which have come from the new third sector providers’ patients. However, my fears were completely misplaced and the organisation running the service now is excellent. I really could not ask for better. All the staff are knowledgeable about the medical, pharmacological and psychological aspect of substance use, and they also have great empathy with the patients, which is absolutely essential.

For the future I do worry what the coming change in government is going to mean for drug treatment. I hope that we aren’t going to go down the road of time limited treatment, discharging patients for positive drug screens, and not allowing patients the chance at getting optimally dosed, which as I know from personal experience, can make such a massive difference to your entire quality of life.

I am so thankful for that doctor that assessed me and realised that I would likely fare a lot better were I optimally dosed. Once that happened I was able to start my life again, and do all the things that everyone else does. Optimal methadone treatment really has given me back my life, and ensured that it didn’t end prematurely.

Having the Alliance to turn to for advice and support was essential to me, and without that I would really have been lost. I don’t think some people understand how stressful and anxiety provoking it can be for a service user when their prescriber wants to make changes to their prescription that the patient is not in agreement with, and an organisation like the Alliance is essential in advising patients whether what the prescribing service is doing is perfectly reasonable and within guidelines, or something that is not in the patient’s best interest and therefore needs further investigation.

To contact the Alliance visit the forum at www.m-alliance.org/forum

 – Sapphire, The Alliance

References

[1]Department of Health (2007) “Drug Misuse & Dependence: UK Guidelines on Clinical Management

10 by 20: HRI calls on governments to redirect 10% of resources from war on drugs to harm reduction

Guest blogger Fionnuala Murphy (Campaigns and Advocacy Manager for Harm Reduction International) introduces the 10 by 20 campaign, calling on governments to redirect 10 per cent of the resources they currently spend in the war on drugs to harm reduction by 2020…

10 by 20 launch photo

This week at the Commission on Narcotic Drugs in Vienna, Harm Reduction International is launching its 10 by 20 campaign, calling on governments to redirect 10% of the resources they spend in the war on drugs to harm reduction.

Call to action infographic

Harm reduction interventions such as needle and syringe exchange and opioid substitution therapy are low cost but have remarkably high impact, keeping HIV infection rates low among people who inject drugs and saving lives and healthcare costs.  Yet many countries still do not provide harm reduction and global funding for it amounts to just $160 milliononly 7% of what is needed.

By contrast, each year governments spend over $100 billion waging an ineffective war on drugs.  HRI is calling on countries to redirect just a tenth of this money to harm reduction.

This 10% could infographic

The 2016 UN General Assembly Special Session on Drugs (UNGASS) presents a major opportunity to secure support for a global target of 10 by 20.  With discussions about the UNGASS taking place this week, HRI is asking country delegations at the CND to ensure that health and harm reduction become central pillars in the UNGASS negotiations and is urging them to champion a global target of 10 by 20.

– Fionnuala Murphy

See full details of the 10 by 20 campaign on the HRI web site

Addiction and recovery research – time for change

An article by guest blogger DJ Mac…

Time-for-changeSMMGP has a great downloadable presentation on addiction treatment research. By Jim Orford, it’s a couple of years old now, but it has not lost any of its relevance. I’ve been writing on the problem of lack of addiction research generally and a definite near absence on recovery research. But we don’t want research for research’s sake; we want addiction and recovery research that is asking and answering the right questions. If we were to come at addiction and recovery research from a different direction, would it help us in a way that traditional approaches have not?

Orford is a Professor of Clinical and Community Psychology at the University of Birmingham. He sets out some of the problems with existing research – why it ‘fails’:

  • It assumes a technological model of treatment
  • It adopts a narrow focus on time-limited professionally dominated treatment
  • It uses an out of date, restricted definition of science and knowledge production

Technological model of treatment

He make a very relevant point around the ‘Dodo Bird Effect’ – the outcome equivalence paradox which views the therapist in an addiction treatment setting as a technician delivering a ‘treatment’ and neglects what we think we know is at the heart of helping people move on – the quality of the therapeutic relationship. So we measure the treatment as the dominant intervention, rather than the personal relationship. The problem with this, argues Orford is that many treatments end up providing much the same kind of outcomes (think Project Match).

His tentative conclusion:

Well-delivered, credible, named treatments are, in most important respects, the same, which would account for supposedly different types of treatment having equivalent outcomes.

Professionally dominated treatment

The problem with professionally dominated treatment is that it tends to ignore professionally unaided change (or, in my experience, resists it); ignores the settings and systems in which treatment is embedded; neglects wider social networks like family and community resources and defines outcomes narrowly. If recovery takes place more in communities than in clinics we are going to miss the impact of community recovery capital on outcomes, something I touched on before.

Restricted definitions of science and knowledge production

Here lie dangerous pitfalls. Research can miss the importance of culture and assume that the findings will be universal. Orford lists more problems:

  • Which assumes research is value-free and researchers are neutral
  • Which privileges top-down expert theory over tacit, implicit knowledge
  • Which ignores the patients view

These chime true for me. The value of lived experience and of recovering people, peer supporting in services has largely been unrecognised. What the patient wants can be lost in delivery of what ‘the evidence’ says works. “Successful” treatment can be one where the patient never reaches his or her goals, but agreed outcomes are still achieved. The service may end up more satisfied than the patient.

In addition there are amazing things happening in recovery communities, in mutual aid groups and in family support services, some of which are peer-led. This is community inspiration, asset building and growth and it is largely not being captured.

Solutions

The prof is not just identifying the problem; he has some suggestions:

  • Stop studying named techniques and focus instead on studying change processes and developing good addiction change theories
  • Study these processes within broader, longer-acting systems of which treatment is a part
  • Bring the science up to date by acknowledging and using the variety of available sources of knowledge (e.g. qualitative research, action research and participative research)

The part that other recovering people (peers) play in recovery from addictions is becoming clearer, at least to those who have eyes to see it. Community recovery capital is on the radar a bit more. Those of us working in treatment need not be afraid of acknowledging that there is more to getting well than professional interventions. When you ask someone in long term abstinent recovery what helped them get there, treatment figures, but it’s not necessarily top of the list and the technical aspects of treatment will hardly be mentioned.

What will be remembered is how kind professionals were, whether we listened to the story, empathised with the struggle and kept faith in them, even when the client struggled to believe in his or her self. In other words, exactly the sort of stuff that traditional addiction treatment research doesn’t measure.

It’s time for change.

DJ Mac

See DJ Mac’s original blog post here
@DJMac_

Case report into naturalistic use of nalmefene within a community alcohol treatment service

A case report by guest bloggers Richard Gray and Dr Tanzeel Ansari

Note: Patient consent was given. Patient name has been changed for purposes of confidentiality

This write up is a single case report into the naturalistic use of nalmefene within a community alcohol treatment service in Nottingham. Nalmefene was given a European licence in 2012 and is intended to be used as a first line pharmacological therapy for the reduction of alcohol consumption in people over 18 years of age with alcohol dependence who are unable to achieve abstinence, or for whom reduction is a more appropriate goal. NICE guidelines CG115 recommends that everyone who fits the criteria for treatment is offered some form of pharmacotherapy. Medication is used for withdrawal and relapse prevention. (The latter include: acamprosate, naltrexone and disulfiram).

It is recognised that not everyone who seeks help for alcohol use want to be abstinent and for some a goal of moderate or “controlled drinking” can lead to more successful engagement. Following nalmefene being granted its UK licence[1] we prescribed it to a patient at Oxford Corner, the statutory NHS community alcohol treatment base for Nottingham City, a recovery oriented specialist alcohol service. Our patient was seen for regular keyworking sessions to explore psychological interventions aimed at moderating his alcohol consumption, alongside the administration of nalmefene, as recommended in the BNF.

A 49 year old Caucasian male “Jonty” was referred in April 2013. At assessment he was consuming in excess of 250 units of alcohol each week. He was drinking standard strength lager (4%ABV), mainly in the evenings after work and all day at the weekends. He was concerned as he had started to drink in the mornings before work.

Jonty described drinking heavily all his adult life, used to drink 9%ABV lager but reduced this to 4%ABV lager following an episode of abdominal pain that may have been pancreatitis. There were no previous episodes of alcohol treatment and no ongoing physical health complications arising from his consumption of alcohol. He wanted to reduce his consumption, but not stop altogether. He also wanted to explore the changes to his lifestyle that this would necessitate.

He was asked to keep an alcohol consumption diary and to record the number of drinks he consumed each day. For simplicity, as he drank the same 4% ABV lager, he recorded number of drinks, which were then converted to units.

Tables 1 and 2

Table 1 shows his baseline consumption in the first two weeks of treatment. On 22nd April he was ill (acute abdominal pain) so didn’t drink at all, otherwise it followed a typical pattern. This gave us a benchmark to work from and he decided that he wanted to work on the morning and the weekday drinking. We set a target of 15 drinks per day during the week. Over the next four months we gradually reduced this target to 13 drinks (see table 2).

Following discussion with Jonty, we agreed to trial nalmefene from 18th October 2013. BNF recommends 1 tablet (18mg) taken as required on each day there is a risk of drinking alcohol. Our patient wanted to see if there was a difference in consumption levels on days with versus days without nalmefene. As he was drinking every day we agreed to try 1 tablet every other day during the week and not at the weekend.

Table 3 shows the number of drinks and days when he took nalmefene over the first two weeks of prescription. Table 4 shows the last two weeks taking nalmefene.

Tables 3 and 4

Figure 1 shows the number of drinks recorded in all diaries till the end of January 2014. Missing data is due to drink diaries lost by the patient, who reported that he continued taking the medication during this period. The time window when nalmefene was taken is recorded above the drinks graph.

Figure 1

At the first appointment following starting the medication Jonty stated that he had found it hard work taking it, mainly due to side effects. He described a “droning” in his head, difficulty sleeping, nausea and dizziness. He did feel that the medication had helped him reduce his consumption and that it had taken the “edge off”- that he was slowing down and didn’t feel like drinking alcohol more. Had been taking the tablet first thing in the morning and did find that the afternoons were particularly difficult. We agreed to switch it to lunchtime administration and continue to take every other day during the week.

By mid-December he described feeling worse, (in terms of the side effects) the day after taking the meds. We discussed whether alternate day dosing may be contributing to side effects. He was due to take some leave from work, and we agreed a subsequent change to daily dosing for two weeks (see table 4).

On 15th January 2014 he reported that he had stopped taking nalmefene on 5th January due to the continuing side effects. His primary concern was that he felt he wasn’t safe at work. He reported feelings that he was being watched all the time and that he was not able to do his job properly, constantly having to check his work and a sense that what he had just done was wrong. Some continued nausea, despite changes made to the way in which he had been taking the medication, was also present.

Interestingly, in the days immediately following stopping the medication he recorded his lowest level of consumption. He said that, without the assistance of medication, he would have to re-evaluate his own motivation in light of skills he had internalised in sessions. He had stopped drinking altogether in the mornings and took to consuming at a slower rate. His overall impression was that the drug had helped him to reduce his consumption by ultimately enabling him to improve his own level of motivation for change. And the overall trend line from the graph bears this out.

 – Richard Gray, (author for correspondence) Clinical Nurse Specialist and Non-Medical Prescriber, Oxford Corner, Nottinghamshire Healthcare NHS Trust, Nottingham NG1 5BH.
richard.gray4@nhs.net

 – Dr Tanzeel Ansari, Consultant Addictions Psychiatrist, Oxford Corner, Nottinghamshire Healthcare NHS Trust, Nottingham NG1 5BH.

References

Nalmefene (Selincro®) for the reduction of alcohol consumption – first line pharmacological therapy for alcohol dependence, Horizon Scanning Centre, University of Birmingham, September 2012

NICE CG115 Alcohol dependence and harmful alcohol use, National Institute of Health and Clinical Excellence, 2011 http://guidance.nice.org.uk/CG115

Nalmefene, British National Formulary issue 66 (September 2013), page 327

NIHR Horizon Scanning Centre, University of Birmingham, September 2012

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[1] British National Formulary, September 2013