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SMMGP Clinical Update November 2007

• Contingency Management
• Primary Care Activity & Attitudes
• Misc
• Last But Not Least

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Contingency Management

We seem to have been covering this a lot in clinical updates, this is because the research literature is crammed with it at the moment. Anyway here are a few examples of contingency management for subgroups we have not yet reported a study on.

Abstinence rates following behavioural treatments for marijuana dependence
RM Kadden et al., Addictive behaviours (2007) 32 (6) pp1220-1236

240 cannabis dependent participants were recruited by advertisement to either: Motivational Enhancement therapy (MET) and Cognitive Behavioural Therapy (CBT); Contingency Management only (CM) or MET, CBT and CM. Contingency management consisted of voucher rewards for cannabis free urines. The two CM cohorts had the superior abstinence outcomes. CM only had the highest rate of abstinence at immediate post treatment. MET + CBT + CM had the highest rate of abstinence at later follow-up.

Voucher reinforcement improves medication adherence in HIV +ve methadone patients: A randomised trial
JL Sorensen et al., Drug and Alcohol Dependence (2007) 88 (1) pp54-63

The primary outcomes indicated that a contingency management intervention was effective in improving medication compliance in HIV+ MMT patients. However differences faded after vouchers were discontinued. Conclusion: CM shows promise in promoting anti-viral medication compliance.

Regardless of psychiatric severity, the addition of contingency management to standard improves retention and drug use outcomes
J. Weinstock et al., Drug and Alcohol Dependence (2007) pp288-296

This study found that psychiatric severity was a predictor of dropout in standard treatment but that with the addiction of a contingency management condition retention was similar across all psychiatric severity. The findings suggest that contingency management is an efficacious and appropriate intervention for substance misuse across a range of psychiatric problems.

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Primary Care Activity & Attitudes

What difference does training make? A Randomised Control Trial with waiting list control of General Practitioners seeking advanced training in drug misuse
J. Strang et al., Addiction (2007) 102 (10) pp 1637-1647

In what is essentially an evaluation of the RCGP certificate part 2 only modest benefits were unambiguously attributable to the course. This seemed mostly due to candidates already having a positive attitude and treating significant numbers of patients. Overall, however, GPs who received training showed markedly greater improvements in knowledge, attitudinal and prescribing confidence measures, and remained more actively involved I treating drug users than GPs who remained in the waiting list control.

Community pharmacies and the provision of substitution services for drug misusers: Changes in activity and attitudes of community pharmacists 1995-2005
J. Sheridan et al., Addiction (2007) 102 (11) pp 1824-1830

This was a follow up survey to one conducted in 1995 which surveyed the activity and attitudes of community pharmacists. This time there was a 95% response rate! There has been a significant increase in the proportion of community pharmacists involved in the provision of a range of services for drug misuse and an even greater increase in the number of patients served. 92% of those dispensing are now willing to supervise consumption, which is potentially an untapped resource. Many (approximately 1/4) were keen to expand their role further into areas such as hepatitis B vaccination. Generally attitudes were more positive than in 1995 and providers were more positive than non-providers.

Worryingly 10% never informed the treating doctor of missed doses and 35% only sometimes reported this.

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Misc

Methadone maintenance treatment: the balance between life saving treatment and fatal poisonings
A Fugelstad et al., Addiction (2007) 102 (3) pp 406-412

This large study studied all individuals who were in contact with the Stockholm methadone programme (n=848) between 1988 and 2000. Mortality was lower in those who remained in maintenance treatment. Those discharged from MMT had a 20 times higher risk of dying of unnatural causes than those who remained in treatment. Fatal methadone related intoxications (across the board) were separately studied and in only 2 out of 81 cases was this due to leakage from mainstream treatment.

Exploring user perceptions of occasional and controlled heroin use, a follow-up study
Tim Mc Sweeney, Paul Turnball, Joseph Rowntree Foundation 2007

This report is a follow-up to earlier research of occasional and controlled patterns of heroin use, which suggested that, for some people, regular use of heroin did not inevitably lead to problems in other aspects of everyday life. The follow-up study located two-thirds of those involved in the original study. It found that Most of the 32 respondents reported having either reduced the frequency with which they used heroin or stopped using. A minority (6) had increased their level of use. This research seems to back up the original research that recreational/regular heroin use does not inevitably lead to dependency and associated problems. The whole report is available at www.jrf.org.uk.

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Last But Not Least

A really important document for members to read and which is a wake up call for all of us whose aim is to prevent and treat injection related infection and harm.

Shooting Up - Infections among injecting drug users in the United Kingdom 2006, An update: October 2007
Health Protection Agency, October 2007

Key Messages

• Almost three-quarters of injecting drug users have been homeless at some time, and those who have been homeless have higher levels of injecting risk and associated infections.
• Injecting into the groin and the injection of crack-cocaine, which are both associated with higher levels of infection and injecting risk, have become more common.
• Overall hepatitis C infection among injecting drug users has increased in recent years, with almost half now infected.
• The level of HIV infection in England and Wales among injecting drug users has increased since the start of the decade to one in 75.
• There has been a marked increase in the number of injecting drug users receiving the hepatitis B vaccine, with two-thirds now reporting vaccination.
• Services to reduce injecting related harm, and to support those who want to stop injecting, should continue to be developed in line with published guidance.

Read the full report at www.hpa.org.uk.

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