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