“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

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

Recovery South African style – SMMGP’s Elsa Browne meets Dr Lochan Naidoo, Durban GP and President of the INCB

A post by Elsa Browne, SMMGP Operational Lead.

On a particularly sparkling sunny morning this week and on a visit to my former home town of Durban, I drove from the upmarket suburb of uMhlanga in the north through the troubled city centre where recent xenophobic clashes had made the BBC news, to the less salubrious southern suburbs where the addictions treatment clinic of Dr Lochandra (Lochan for short) Naidoo is located. Dr Naidoo is a Durban GP, and since 2014 President of the International Narcotics Control Board, the first Southern African; and family practitioner to be elected to that role. In this role, he works with high-level delegations from the World Health Organisation and makes presentations to the UN’s Economic and Social Council and the Commission on Narcotic Drugs. Dr Naidoo was a founding member of the International Society for Addiction Medicine in the 1990s and a plenary speaker at the ISAM conference in 2014.

Like many of his counterparts in the UK, Lochan is passionate about all things related to the subject of addiction. He works as the clinical lead of a private residential rehab in Merebank south of Durban, which he established some 20 years ago as a young general practitioner. On arrival at the spotlessly clean and welcoming clinic I was met by the centre’s psychosocial therapist and shown around the premises, including meeting the genial chef. The walls of the clinic are decorated with posters carrying familiar slogans – Dr Naidoo did a residency at the Hazelden Centre in the US during the 1990s. In a country like South Africa with its many competing health priorities, his determination to keep addiction prevention, treatment and policy on the agenda is crucial and has led him from national partnerships to his current position and international links.

None of the above however takes his focus away from the starting point: people who use drugs problematically. Each and every individual that enters the clinic is case managed by Lochan in person, together with the wider multi-disciplinary team of trained professionals, psychiatrist, psychologists and social workers. The drugs of choice of people that come through the door reflect local trends and are ever more challenging, including an upsurge in the use of heroin or heroin based drugs mixed with anti-retrovirals. Opioid substitution medication – expensive in South Africa – is prescribed. He dismisses a question about his views on pursuing abstinence with a smile and a small shake of his head: “I believe we can all be fully integrated human beings”. And further: “Often the architecture of a troubled life is shaky and unstable. I don’t offer to treat addiction, it’s there. What we do is, together we build a new structure adjacent to the old one, a strong and stable one. And when the new construction towers over the old one, people come across and inhabit it permanently”.

In order to be funded for treatment, people entering treatment have to navigate the South African system of medical aid provision or employee assisted programs. In a genuine and innovative collaboration with its population, the clinic has a web-based system for patient notes and treatment plans (Roots), developed by Lochan, that patients themselves can log into from anywhere allowing them to share it freely with anyone, such as family members and even employers. Once the recommended 28 day programme is completed (longer for some), graduates are welcome to continue to log in to Roots, come to the clinic, attend the drop in, use the facilities such as the computer room, build enduring relationships and provide a glimpse of a possible future for those entering treatment.

As we browsed the SMMGP website together, Lochan was envious of our “brilliant resource” – and wanted to know who funds us. I explained that until fairly recently we were able to attract government funding, but given the current parlous state of funding for the addictions field in the UK, we were in a sense in a similar position to our South African primary care counterparts in terms of zero government financial support for clinical networks. He is concerned that there is no academic centre of excellence for addictions in South Africa and will continue to strive to position the country strategically on the international addictions platform, as he did when he was invited to present on addiction as a non-communicable disease (NCDs) at the United Nations General Assembly high level meeting in New York in July 2014. The meeting undertook a comprehensive review and assessment on the prevention and control of NCDs – chronic diseases that affect the poorest in the world.

As I prepared to leave, I asked whether people from the leafy northern suburbs of the city come to the clinic too. “Of course” came the response “when they are ready”.

Dr Naidoo may have been envious of our comprehensive guidance documents and supportive network, but as I walked out through the rainbow collective of people leaving the morning “Contemplation Meeting” that reflected true diversity including across the spectrum of recovery, I felt envious too. There is much we can learn from each other and you may find Lochan popping up on the SMMGP Clinical Forums sometime soon.

– Elsa Browne
SMMGP Operational Lead

Learn more about Dr Lochan Naidoo, INCB President

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

Treatment complete?

Dr Steve Brinksman writes the regular “Post-its from Practice” articles for Drink & Drugs News (DDN) Magazine. The most recent Post-it (Nov-2014) appears below with kind permission from DDN.

There is yet a lot of – sometimes heated – debate about whether drug services should be recovery or harm reduction based and some people seem determined to pursue this as a doctrine of dichotomy rather than as part of the same spectrum. Yet I rarely hear the same passion when we talk about treating viral hepatitis. Services will talk about high levels of BBV screening and uptake of hepatitis B vaccination and yet have tiny numbers of service users going into hepatitis C treatment. Now I admit that I am biased – a good friend and colleague, who did more than anyone else to show me how important it was to treat drug users, died of hepatocellular carcinoma, caused by his hepatitis C. To my mind the failure to get people into treatment that will not only potentially save their lives but also save large amounts of NHS funding, is a travesty.

We have effective and ever improving curative treatments and yet many people languish in primary care and community based services knowing they have chronic hepatitis, without referral or with high “DNA” rates for those who do get a referral. Perhaps we should stop talking about hard to reach patients and start accepting that we have hard to access treatment services instead.

We need to acknowledge that the current provision of BBV care for those who are in drug treatment is failing. And if we can’t get those who are being seen regularly and supported by clinicians and key workers into treatment for their viral hepatitis then what hope of treatment is there for those who aren’t on substitute prescribing and who are not in established treatment?

Treating people who inject drugs has been shown to be effective and reducing the pool of people with chronic infection can help lessen the spread. We need to create systems to support people into and through treatment and these are the sorts of outcomes that should appear in primary care and community based drug treatment tender specifications. Public Health, Primary and Secondary care all working together – perhaps we could call it something radical like a National Health Service! – to design a service that delivers effective, evidence based treatment that saves lives, reduces disability and saves money.

At the SMMGP conference in Birmingham during October we heard about a pilot project in Birmingham where the specialist hospital staff will be going out into primary care and delivering treatment alongside service users’ regular reviews and key working sessions. I know similar services exist in Newcastle, Nottingham and London.

The newer anti-viral treatments are producing cure rates of over 90% even in the more difficult to treat genotypes of hepatitis C. Even newer treatments promise “tablet-only” therapies that will minimise many of the side effects and adverse events seen in current treatment, albeit at greater financial cost but yet these will still be cost effective interventions. The only way we can advocate for these treatments to be available for our service users is to have the right systems in place to make sure that they are screened, referred and supported through treatment. The health gains for someone who has successful viral hepatitis treatment are immense and at least as important as them being “discharged treatment complete”.

– 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.

The golden key (worker)

Dr Steve Brinksman writes the regular “Post-its from Practice” articles for Drink & Drugs News (DDN) Magazine. The most recent Post-it (Sep-2014) appears below with kind permission from DDN.

For the past six months my practice has been providing the medical cover for some of the homeless and vulnerable persons’ drug service sessions in Birmingham. Due to the fact that the doctor who usually covers these clinics is on sabbatical, it has been my privilege to do these clinics for the last three months.

Most of the patients are IV poly-drug users, many are rough sleeping, and there are high rates of Hepatitis C, much higher rates than usual of HIV. A lot are groin injectors and DVTs and cellulitis are common and we had one patient recently who had a femoral artery pseudo-aneurysm rupture but fortunately survived.

The police have of late started to clamp down on begging and many of the patients have received criminal anti-social behaviour orders and are banned from large chunks of the city centre that makes collecting their prescriptions and attending appointments, a breach of their orders. There are no safe places to inject so under flyovers, on flat roofs and in bushes by car parks there is needle litter and desperate people hurriedly injecting with all the risks that entails. This may make grim reading and sound very negative and indeed much work is needed to change some of the attitudes within authority.

However my time there has felt incredibly positive as despite these problems the staff are highly motivated and committed to working with this group, both through key working and support from the clinic, but also outreach. I was buoyed by their resilience and enthusiasm and reassured to see how individualised the care was for each and every client.

For me this has emphasised again the essential role the key worker has in an individual’s treatment journey. For the first 12 years I attempted to treat people with problematic drug use at my practice, they had to go elsewhere for keyworker support, this disconnect meant much higher drop out rates, difficulty in communication and multiple journeys and appointments for the patients. The day when the shared care system in Birmingham formally launched and we had key workers in our GP surgeries was probably the most effective change that has happened in my career.

I have come to realise over the years that whilst a prescriber’s role is important what we do by providing a prescription for OST is give people a choice. Without a script they have little option but to use drugs. On a script they have a choice to not use, however the confidence and ability to do that comes from within them and is usually a result of the strong therapeutic relationship that effective and caring key work brings.

Working with people who use drugs problematically needs a true multidisciplinary approach; the bedrock of this is carers, peers and social support, but within treatment systems it needs doctors, nurses, pharmacists, counsellors and key workers who care about their clients and who communicate and work together to deliver the needs identified by the individual patient across the whole spectrum of treatment – from harm reduction to supporting abstinence.

– 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.

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_

Jack and Bill from the service up the hill

Dr Steve Brinksman writes the regular “Post-its from Practice” articles for Drink & Drugs News (DDN) Magazine. The most recent Post-it (Jul-2014) appears below with kind permission from DDN.

It is my firm belief that the majority of people with drug and alcohol problems can be managed in primary care, albeit with the proviso that appropriate access to psychosocial treatments are in place. I was initially therefore fairly downbeat about having to refer Bill back to our local secondary care provider.

He and his brother Jack are both registered at our practice and have been for a number of years. Now in their late forties, they each have a long history of chaotic IV polydrug use and alcohol dependency punctuated by numerous prison sentences.

Over the years their lifestyle has taken its toll and they both have a number of physical health problems mainly related to alcohol use and previous encounters with mental health services with diagnoses of explosive type personality disorders.

Jack, the older of the two, was being treated by the secondary care drug service for a number of years when we were approached to see if his care could transfer to our practice as due to some of his other problems attending the CDT was becoming more difficult. In the 3 years since then there have been spells when he has lapsed into more problematic drug and alcohol use, however with a lot of input from his keyworker based at our surgery we have succeeded in integrating his care into our practice. This is also testament to the skill of our receptionists who have managed to build a good rapport with him that on the whole nullifies his occasional outbursts.

Perhaps feeling flushed with success we then agreed that his brother Bill’s opioid prescribing could also be transferred over from the secondary care provider to us. Despite trying the same approach as we used with Jack, this has been much less successful. Three local pharmacies have barred him due to abusive language and he would regularly cancel or not attend key worker or doctor appointments, only showing up finally if the script was altered. His alcohol use escalated and he was verbally offensive to the receptionists on several occasions despite this being discussed with him by both doctor and keyworker.

We have a policy of discussing patients with any conditions whom we are struggling to manage either clinically or behaviourally at our weekly practice clinical meeting. As a result of one of these discussions it was decided to transfer Bill’s care back to the secondary care drug service.

This was a difficult decision to make and made me realise that whilst we may be fortunate within our team to have the clinical and case management skills available to support less stable people the roles of other staff and colleagues are equally important. Primary care is a fantastic place to deliver care to those using drugs and alcohol problematically, however some will need extra support and care and I am grateful that additional services are available.

Bill still comes to see me and we are now starting to address some of his physical and mental health issues and our discussions are no longer dominated by requests for changes in prescriptions. I hope that at some point in the future he may again receive all of his care at the practice but for now transferring his opioid substitution treatment out has meant he has remained a patient at the practice. For all concerned – a positive outcome.

– 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.

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