Scanbites Winter 2007 Vol 4 Issue 4

2007·0.98 MB·English

by  Specialist Clinical Addiction Network

The new Orange
Guidelines are essential
reading for all clinicians
who manage drug
misusers
The quarterly newsletter of the Specialist Clinical Addiction Network | WINTER 2007 | Vol 4 Issue 4
ISSN 1744-6112
Editorial
The future is still orange!
SCAN members should by now have
received their Xmas present from the
SCAN team by post, in the form of the
2007 edition of the “orange”
guidelines on clinical management of
drug misuse and dependence! We
welcome the publication of this
document. The last edition, published
in 1999, while helpful in its time, had
been overtaken by advances in the
evidence base and the publication of a
myriad of policy documents,
frameworks, guidelines and technology
appraisals.
So a new edition is timely to set
the expected clinical standards for
practitioners in the field and to provide Blood-borne viruses: the role
a framework for the delivery of best
practice in the context of the available of addiction services
evidence, the relevant legislative
framework, and NICE
recommendations. Dr John Dunn – Lead Consultant in System has two data fields for hepatitis B and C
What are the implications for Substance Misuse, Camden & Islington testing status and a further field for the number of
SCAN members? First, we feel that the Mental Health & Social Care Trust, London hepatitis B vaccinations received. (See box 1.)
new guidelines are essential reading for and Clinical Team Lead, National Treatment Although these questions are self
all clinicians who manage drug Agency for Substance Misuse*. explanatory, there needs to be consistency and
misusers, medical practitioners in reliability in how and when they are asked and by
particular. The foreword states that, whom.
although the guidelines “have no
THErecent NTA/Health Care Commission For example, at one extreme generic drugs
specific statutory status….any clinician
Harm Reduction Audit revealed a wide workers with limited competencies for, and
not fulfilling the standards and quality
diversity of practice in substance misuse knowledge of, blood-borne viruses (BBVs),
of care in the appropriate treatment of
partnerships in relation to overdose working in a satellite service with no other health-
drug misusers as set out in these
prevention, prevention of drug-related deaths, care professional available, may simply ask if the
guidelines will have this taken into
screening and vaccination for blood-borne client has ever been tested.
account if, for any reason, their
viruses and needle exchange provision. In this If the client replies “no”, he or she may be
performance in this clinical area is
article I propose to focus on blood-borne signposted to the nearest testing and vaccination
assessed.”
viruses, in particular what drug treatment service, with the “offered and accepted” boxes
We take this to mean that the
services can do to ensure that the maximum being ticked, even if the client never makes it to
General Medical Council and other
number of at-risk clients are offered screening the appointment. At the other extreme the client
statutory bodies will use the guidelines
for blood-borne viruses and vaccinated against may be assessed by a BBV nurse or a doctor, have
as the standard for expected practice.
Those practising markedly outside of hepatitis B. the blood taken for screening and given the first
hepatitis B vaccine, all at the same appointment,
these norms run the risk of censure.
This should help to standardise and rein What are we being asked to monitor? and with the same box being ticked.
in some of the extremes of practice The National Drug Treatment Monitoring
page 2, column 1 ➔
page 3 ➔
Opioids and
Influencing Review of the heart8 managing
alcohol policy new Clinical suicide
An interview with Guidelines6 risk9
Prof Ian Gilmore 4
www.scan.uk.net
BLOOD-BORNE VIRUSES
Blood-borne viruses: the role of the addiction specialist
We performed an audit of all clients entering laboratories do this automatically on all
➔ NDTMS data fields for hepatitis our prescribing programme over a six-month antibody positive results, others only if
1. Hepatitis B intervention status period and found that 76% reported previous requested to, so writing on the request form
(cid:129) offered and accepted tests for blood-borne viruses, which had been “do PCR if antibody positive” will save the client
(cid:129) offered and refused undertaken by a range of services including: from having to be re-bled.
(cid:129) not offered prison healthcare, GPs, specialist hospital The PCR test detects hepatitis C RNA
(cid:129) immunized already
inpatient or outpatient services and other drug which shows that the virus is actively
(cid:129) acquired immunity
treatment clinics across the full range of tiers. replicating. If the PCR result is negative
2. Hepatitis B vaccination count
Eighteen percent said that they had received (“undetectable”) then the person has
(cid:129) one vaccination
some or all of their hepatitis B vaccinations. spontaneously cleared the virus and is no
(cid:129) two vaccinations
Some test results, once positive, will stay longer infectious. This would also be the results
(cid:129) three vaccinations
positive and do not need to be repeated (e.g., if the client had been successfully treated for
(cid:129) course completed
hepatitis A antibody, hepatitis B core antibody, hepatitis C and had a sustained viral response.
3. Hepatitis C intervention status
(cid:129) offered and accepted hepatitis C antibody and HIV antibodies). Approximately 20% of hepatitis C antibody
(cid:129) offered and refused However, in all cases it is important that positive individuals spontaneously clear the
(cid:129) not offered ❶ documentation of these results is based on virus without treatment. There is evidence that
BOX objective evidence rather than relying on client a person can be re-infected with hepatitis C, in
report. The audit that we undertook illustrates particular with a different viral strain.1
Past results the high level of past testing that clients have If the PCR result is positive (“detectable”),
For hepatitis B the “immunized already” and been exposed to and demonstrates that a then the virus is actively replicating and the
the “acquired immunity” data fields raise significant proportion of clients falls into the client is infectious. Some laboratories will
questions about the reliability of patient recall category of having results that once positive do automatically report the PCR viral load on all
in relation to blood test results. In an audit we not need repeating. See Box 2. PCR positive samples.
undertook in North London, the reliability of HIV – antibody.Laboratories often test for both
self-reported hepatitis and vaccination status Hepatitis Audit results HIV 1 and HIV 2 sub-types. If the test is positive
was low. (cid:129) 76% of clients starting treatment had had the client has been infected with HIV. If
This is not too surprising when one takes previous BBV screening. negative, infection has not taken place, but if
into consideration the range of possible (cid:129) Of those clients for whom results were the client is involved in risk behaviour, they are
results: there are three types of hepatitis available: 41% were hepatitis B core vulnerable to future infection. Clients with a
commonly tested for along with HIV, any of antibody positive (i.e. acquired immunity). positive test result will need a second
which the client may have been exposed to, (cid:129) 68% were hepatitis C antibody positive confirmatory test – either a second antibody
three of which can lead to chronic infection, (cid:129) 20% of hepatitis C antibody positive clients test or an HIV viral load.
and two of which the client may have been were PCR negative: many of whom were at For all these blood-borne viruses, there is
partially or completely vaccinated against, low risk of re-infection. ❷ a window period between initial infection and
giving a very large number of possible status BOX the development of the antibody response.
permutations. Therefore, should these boxes Therefore, if exposure is recent the test will
be filled in only if there is objective What should we test for? need to be delayed or repeated when this
confirmation of past results and vaccination Hepatitis B – surface antigen and core window period has passed.
records? If so, how can we obtain past results, antibody.In some laboratories a request for a The new Clinical Guidelines give detailed
which may have been filled in prison hepatitis B screen may result in only the information on prevention, diagnosis,
healthcare records, GP records, hospital case surface antigen being tested for. This is investigation and treatment of blood-borne
notes or drug treatment service records? particularly true of antenatal services, where viruses within the wider context of addressing
Because the client will need to give written current infection is the focus of investigation. the health needs of drug users.2
consent to obtain previous results, a standard This needs to be borne in mind if past results
letter requesting them, with a space for the are being sought, so the context of the testing Cost of testing and vaccination
client’s signature, would be a useful aid. We is important. If the patient reports having been Box 3 shows the cost of a range of antibody
have tried using such a letter in the service vaccinated in the past, it would be useful to test tests obtained from a local NHS Trust in May
where I work with a high level of response, as for the surface antibody, which is what the 2007. The prices of the vaccines were obtained
long at the previous treatment service can be vaccine induces. A client with acquired from the March 2007 edition of the British
reliably identified. immunity will have a positive core antibody and National Formulary.
But is it worth making the effort to obtain this result will not change and does not need to
past results when the client could simply be be repeated. A client who is negative for both
asked to give consent to have the blood tests the surface antigen and the core antibody has Cost of antibody tests
repeated? The answer is not straightforward, not been exposed to hepatitis B and is (cid:129) Hepatitis B surface antigen (HBsAg) £10.00
and has four components: therefore vulnerable to infection and should be (cid:129) HB core antibody £10.00
i what proportion of clients have been vaccinated, unless this has already happened. (cid:129) HB s antibody £10.00
previously tested? Hepatitis C – antibody. (cid:129) Hepatitis C antibody £15.00
ii might the result have changed since last An antibody negative result usually means that (cid:129) Hepatitis C PCR £75.00
test? the client has not been infected with hepatitis (cid:129) HIV 1 and 2 £10.00
iiiwhat savings might be accrued from not C but is still vulnerable to infection if he or she (cid:129) Hepatitis A antibody £10.00
repeating tests unnecessarily? continues to be involved in risk behaviour. A (cid:129) Hepatitis A vaccine x 2 £38.38–£47.62
ivdepending on the state of the patient’s positive antibody result shows that the client (cid:129) Hepatitis B vaccine x 3 £37.03–£38.97
veins, how accessible are they to has been infected with hepatitis C, and a PCR ❸
venepuncture? test should then be performed. Some BOX
2SCANbites | WINTER 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS
EDITORIAL / CONTINUED
At the recent SCAN conference a question was phlebotomist. In some specialist hospital ➔ occasionally encountered, and this is to
raised as to whether it would make more outpatient clinics, such as diabetic clinics, be welcomed.
sense to vaccinate all clients against hepatitis administrative staff have been trained in basic Second, the guidelines are about
B, rather than testing them all and only clinical skills such as phlebotomy and urine promoting the quality of treatment
vaccinating those who are susceptible to testing, so in principle this is an area generic rather than the quantity, which is also to
infection. Taking only the cost of the vaccine drugs workers and even reception staff could be welcomed. However, we anticipate
into consideration, to vaccinate 100 clients be trained in. However, it is important to that this may throw into sharper relief
against hepatitis B would cost around £3,897. distinguish between the skills and some of the existing conflicts between
If they were all screened first and only the competencies needed to take blood and those the commissioning agenda and
60% who did not have acquired immunity needed to discuss the pros and cons of having clinicians providing the best care to
Dr John Dunn
were vaccinated, the total cost, including the the blood test with a client, the interpretation individual patients. Commissioning
laboratory costs of the appropriate hepatitis B and explanation of results and the discussion continues to be led by patient volumes,
antibodies and antigens, would be around of appropriate care pathways and treatment and waiting time and retention targets
£4,338. So at the individual treatment service options. which are closely monitored. The
level it might make financial sense to vaccinate The ‘when’ and ‘where’ of testing is also guidelines on the other hand aim to
all clients as they present to treatment. It an area for discussion. A variety of models are raise the standards of individual care
might also improve overall vaccination in place around the country. These range from based on best evidence. But many of
the treatments recommended in the
completion rates by starting this process at the peripatetic BBV nurses who do outreach work
guidelines are not routinely available in
point of initial assessment, rather than having or satellite clinics in a range of drug treatment
all services. For example, some services
to wait for test results to come back first. services to more centre-based testing and
are currently unable to prescribe
However, if the majority of clients have vaccinating services. Opportunistic testing is
methadone or buprenorphine according
had previous contact with treatment services often seen as the way of ensuring that as many
to patient need, or with the level of
(specialist prescribing, GP, prisons, detox and clients as possible are tested, by offering the
monitoring recommended, due to
rehab, etc), then the cost to the whole health intervention whenever they happen to be in
limitations of prescribing budgets or
system of repeatedly vaccinating clients, who the service. In this model clients would be
service level agreements written, in
during a drug using career may have multiple able to access BBV services when they attend
some cases, many years before
contacts with treatment services, could be for their usual appointments or when picking
publication of these guidelines. Also
very high. At present we do not have a reliable up prescriptions or medication. Anecdotal
interventions such as family therapy or
system for confirming which clients have reports suggest that appointment-based BBV References contingency management, while
already completed their course of vaccines, so services are not the most efficient way of
promising, may be difficult to
some level of repeat vaccination would be working with this client group. 1 Micallef, J.M. et
implement without additional funding.
inevitable. Electronic databases can be useful aids for al. (2007) High
So there is a danger that practitioners
A major disadvantage of vaccinating all readily identifying clients who have and have incidence of
hepatitis C virus are caught between trying to comply
clients against hepatitis B without screening not been tested and for programming
reinfection within a with conflicting requirements. On the
them first, would be that clients with chronic reminders for when vaccinations are due. cohort of injecting plus side, however, the guidelines
hepatitis B or those acutely infected but drug users. Journal should provide an authoritative
asymptomatic would not be identified. There Care Pathways of Viral Hepatitis, reference point for discussions between
is now effective treatment for patients with It is important that clear care pathways are 14 (6): 413 – 418. practitioners, NHS trusts and
chronic hepatitis B and clients with acute developed for clients whose blood results will 2 Department of commissioners locally, as well as
infection require monitoring. require a specific action plan, for example, Health (England) national policy developments.
The true cost of vaccinating all comers or acute or chronic hepatitis B, chronic hepatitis and devolved Third, we welcome the document’s
testing and selectively vaccinating susceptible C and HIV infection. Referral rights for administrations. emphasis on clinical governance as a
(2007) Drug
clients goes beyond the cost of the vaccines specialist consultation need to be clarified and guiding principle for best practice. While
misuse and
and tests and includes that of employing staff rapid access to specialist HIV services for dependence: UK this has been a key plank of improving
to take blood, administering vaccines, newly diagnosed cases. From a training point guidelines on quality in the NHS for the past decade,
transport, interpreting results, referring clients of view, Specialist Registrars would be advised clinical we feel clinical governance has so far
to specialist treatment services, etc. The only to gain knowledge of the treatment management. received insufficient attention in
way to resolve this issue would be by interventions available for hepatitis C and HIV, London: guidance specifically related to the drug
evaluating the true costs of different models of perhaps by sitting in on specialist clinics Department of misuse treatment field. SCAN is
BBV service provision. [Presumably also the during their special interest sessions. All drug Health currently scoping ways in which it can
cost of treating patients who do not complete treatment services should foster links with support clinical governance at a national
* This article is
the vaccination course and go on to develop their specialist hepatology and HIV services so level.
based on a
severe liver complications would also come that they can liaise over clients in common, Overall, the new clinical guidelines
presentation at the
into this calculation, and could have a major where consent for this has been obtained. last SCAN are a welcome and timely development.
impact on the cost effectiveness of routine Some specialist HIV and hepatology conference and What is now needed is consideration of
vaccination - Ed.] services have developed outreach clinics in was developed how clinicians can be supported to
drug treatment services and work closely with prior to Dr J Dunn implement them fully, and a debate
Who should test, when and where? substance misuse BBV nurses. This is an area taking up his post about how the conflict between
A wide range of professionals could do the that would benefit from expansion, at the NTA. The quantity and quality of treatment can be
screening for blood-borne viruses as long as particularly in the hepatitis C field, where views expressed in addressed. This is unlikely to happen
they have the skills and competencies to do unless we engage significantly more clients in this article are instantly, but at least the future is still
those of the author
so, for example: a blood-borne virus nurse, treatment we cannot hope to have any impact do not necessarily orange!
any competent nurse, a GP, an addiction on the prevalence and incidence of hepatitis C represent the views Prof Colin Drummond, SCAN lead &
psychiatrist, any competent doctor or a infection. of the NTA. Dr Judy Myles, SCAN policy advisor
SCANbites | WINTER 2007 3
INTERVIEW
Bringing the
more alcohol related problems in acute
hospitals. Many of them are frustrated
field together because they have tried for some years to
get more support to develop alcohol
services. Addiction psychiatry services are
on alcohol very thinly stretched in many parts of the
country.
We need a ‘champion’ for alcohol services in
and public
each hospital to ensure that the issue is
taken seriously and initiatives are introduced.
health Also I think that a modest investment in
alcohol health workers is the biggest single
difference that could be made in acute
hospitals. The culture needs to change.
Professor Ian Gilmore is the Health professionals need to realise that
President of the Royal College of these are not heart sink or revolving door
patients, and we can actually do something
Physicians and a consultant
useful across the spectrum, from those
gastroenterologist in Liverpool. He
people drinking hazardously to the severely
has a longstanding interest in dependent. There are options other then just
alcohol policy and has recently sewing them up and sending them out
again from the A&E!
formed the Alcohol Health Alliance
as a means to bring the field CD Some alarming official statistics on
together in raising the profile of the increasing number of people with
alcoholic liver disease being admitted to
the health harm of alcohol on the
hospital were published recently. What
public policy agenda. Colin do think are the drivers behind that
Drummond interviews him for increase?
IG There is no doubt that alcoholic liver
SCANbites.
disease and other alcohol related health
conditions are increasing in the UK. When
you look at the general population
consumption data, such as the general
household survey, we are drinking more than
CD How did you become interested in 20 years ago. But the rise in alcoholic liver
alcohol issues? disease is disproportionately greater than
IG What I should make clear from the start is could be explained by this alone. A lot more
that I am not an addiction specialist and have research is needed to understand the
no expertise in that area but I did work for 6 relationship between drinking and liver
weeks as an auxiliary in an acute psychiatric disease. ...there is a huge
ward while I was a student at Cambridge. I
also did a degree in psychology at CD You have highlighted the issue of health inequality issue
Cambridge, and maybe that was one reason people starting to drink extremely
in the physical and
why I didn’t become a psychiatrist! But my heavily at a younger age, young women
way into alcohol related problems was in particular. Do you think that changes
mental consequences
through being a liver specialist. I started off in in the way that young people are
general medicine, and it was the liver side of drinking may be partly responsible for of alcohol misuse
gastroenterology over my 25 years or so as a this change in prevalence liver disease?
consultant that has interested me most. IG I am sure people starting to drink heavily
Alcohol is the most common cause of liver at a younger age is the cause of the shifting
damage and therefore one inevitably age spectrum of liver disease, and why we
develops an interest in alcohol issues. Later are seeing this in people in their 20 or 30s IG I welcome a fresh look at this. Certainly
when I was Registrar of the College, Sir with established liver problems. But whether we argued strongly that liberalising the
George Alberti encouraged me to set up a there has been a more fundamental effect of licensing law was unlikely to change the
working party to look at the impact of alcohol people starting earlier and whether there is culture as the government thought it might.
on the NHS and how can the NHS afford it? an increased vulnerability in young teenagers I think my phrase on the Today programme
is currently unclear but would be very that gained some currency was that ‘it is
CD Do you think more could be done to interesting to look at. fanciful to imagine a change in licensing
tackle the problem of alcohol in the hours would lead to a wine sipping
general hospital setting? CD The government has recently continental culture’, which proved to be the
IG I think that there is still a lot more could signalled a review of the licensing case. Rather it has probably made matters
be done. We have just done a survey of changes that occurred two years ago. worse, with some evidence such as the study
gastroenterologists, and they report seeing What do you think should happen now? from St Thomas’ Hospital, that there is a
4SCANbites | WINTER 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS
what that is and what are its aims? existing laws on serving alcohol to under age
IG As the name implies it is an alliance and drinkers and serving people who are drunk.
we are not seeking detract from the identity We also advocate proper implementation of
of the parent bodies that are represented. the existing code of advertising and, where
But it became apparent to me and other appropriate, extending regulation, for
health colleagues, firstly that the spotlight example, on the watershed for advertising
always seems to be on antisocial behaviour alcoholic beverages and looking at sport
and crime rather than the health sponsorship by the alcohol industry.
consequences. This is probably because it is
easier for the alcohol industry to focus CD How do you feel that other colleges
concern on, and to demonise, young people like the RCPsych and addictions
getting drunk on a Saturday night. So our specialists in particular could help to
first concern is to get the spotlight back onto support this intuitive?
the even more serious health problems of IG We have been delighted from the
alcohol misuse. enthusiasm and support from all the players
Second, I was aware that many of us were in the field. In particular the RCPsych and
talking to the media and trying to influence addiction specialists have been really positive
the government in a genuine way but not in offering support and involvement. I think
always using the same arguments. that addiction specialists recognise that there
It is very easy to dismiss advice if there are has been a mismatch of government support
differences between organisations by saying for illicit drug problems versus alcohol harm.
‘if they can’t agree amongst themselves, That doesn’t mean to say that we wish to
then why should we listen?’ So the idea was see resources being taken away from drug
bring the various players in the field together services, but the balance is clearly not
to agree on key priorities, and where reflected to the degree of harm in society.
possible to agree a key ‘core script’ so we
could be effective in putting the health case. CD The government recently
The longer term aim is to spawn a more announced a new public service
cohesive influential lobbing organisation. An agreement target to reduce the number
analogy that came to mind was Action on of alcohol admissions to hospital. Do you
Smoking and Health, which the Royal think that will have any impact?
College of Physicians formed in 1971 for IG I hope so. I have certainly been
very similar reasons. The College has a very heartened by visiting various PCTs and
wide health remit and campaigning is not hearing how they acknowledge that alcohol
our main business. But I think there is a need is now a key factor in the health of their local
for some serious campaigning in the field of community. While there are real signs of
alcohol misuse so it would be very helpful to progress on how well they tackle cancer and
have another body out there that we are heart disease, alcohol related health harm is
able to support, but we are not directly bucking the trend as the one area that is
responsible for on a day to day basis. increasing. I think that one of the key
concerns that Sir Michael Marmot has drawn
CD What are the plans for the Alcohol attention to is the fact that we may be
Health Alliance? drinking more across the board in all
IG We had a successful launch about two socioeconomic groups, but it’s the poor and
weeks ago and produced the document the disadvantaged who seem to be bearing
with key messages that went to the media a disproportionate brunt of the damage. So
and to all MP’s and other bodies. We did there is a huge health inequality issue in the
agree a core script and there were three physical and mental consequences of alcohol
areas the Alliance has highlighted. One was misuse.
that alcohol treatment and prevention
programmes should be better funded. With CD We have had a long period in the
so many alcohol dependent individuals in the UK in which there has been a policy
bigger burden on the A&E department, and country, our concern is to draw attention to vacuum around alcohol issues. Do you
presentations are spread throughout the the scandalous lack of access to good feel more optimistic now that we are
night rather then peaking at what was treatment facilities right across the spectrum starting to move forward in the right
previously the universal closing time. But I from early interventions to inpatient direction? We need a
have always been more concerned about the programs. The second key issue was that we IG I have been involved, at least peripherally, ‘champion’
impact of the off licences sales (24 hour should concentrate on evidence based in alcohol policy making in the last eight for alcohol
supermarkets, corner shops, petrol stations), health policies, including price and years, and I do sense that we are maybe near services in
and I think this is the area that the availability. The obvious way to modulate a tipping point that perhaps took 45 years to each hospital
government should look closely at that. price is through taxation which could have achieve in relation to smoking. I think there is to ensure that
large impact on the alcohol problem. The a recognition that we can’t afford to wait 45 the issue is
CD You have recently launched the third area was stronger industry regulation, years to bring about changes in the way that taken
Alcohol Health Alliance. Can you tell me firstly through better enforcement of the our society handles alcohol. seriously.
SCANbites | WINTER 2007 5
REVIEWS
Drug misuse and dependence
UK guidelines on clinical management, 2007
Dr Fleur Ashby, 2007 has brought the arrival of the note there is a change to guidance
Consultant in new and updated “Orange Book” – on supervised consumption, which
Substance Misuse
Drug misuse and dependence: UK breaks from a rigidly interpreted
and Dr Eric Dale,
guidelines on clinical management.1 three months of supervision and
ST4 trainee,
Barnsley. Its predecessor from 1999 has been emphasises the role of clinical
the ‘bible’ of clinical practice for the judgement. This is recommended for
last eight years and during this time both methadone and buprenorphine;
addiction services have seen many which may be an issue for some
developments: the launch of the services.
National Treatment Agency; Models Chapter 6 covers harm
of Care and more recently two NICE minimisation, testing for blood-borne
guidelines. The new guidelines, viruses and drug misusers who
published jointly by DH and the misuse alcohol or tobacco. Advice is
devolved administrations, are a given on management of hepatitis A,
welcome addition, which promise to tetanus and tuberculosis in addition
enhance and give structure to our to Hepatitis B, C and HIV. One The increase in numbers of older
clinical practice. They are evidence- recommendation is that those who drug misusers in treatment is
based and throughout the whole continue to inject drugs or use considered. Care is recommended in
document there is reference to NICE. alcohol should not be excluded from this group with co-morbid physical
Of note in chapter 2 is the antiviral therapy as a result of these problems, and with drug
information on non-medical behaviours. Advice from the 1999 interactions. Advice is given on pain
prescribing, which is divided into guideline on cleaning injecting management for opioid users in
supplementary and independent non- equipment to reduce risk of HIV acute and chronic pain. The
medical prescribing. The section on transmission has been removed from opportunities to engage people in
the roles of doctors in treating the current guidance. Advice is given hospital or A&E are acknowledged
substance misuse, part of chapter 2 on referring patients to smoking with a minimum of health advice and
in the 1999 edition but currently in cessation services. service information provided.
Annex A1, has been expanded to In chapter 7 specific populations The annex provides invaluable
include “other doctors caring for are discussed. All prisons should information on prescription writing,
substance misusers”. This includes promote safer injecting practices in patients travelling abroad, driving
GPs providing all levels of care within prisoners who continue to inject. and on drug interactions. There are
a variety of service delivery models. Advice is given on maintenance also principles of prescribing
Chapter 4 is dedicated to the treatment and on detoxification in injectable opioids taken from the
psychosocial components of prisons. Before release re-induction 2003 NTA document.2Of particular
References treatment. The first part is a onto substitution treatment should interest is the inclusion of cardiac
thorough description of key working, be considered. assessment and monitoring for those
1Department of incorporating the value of the In terms of pregnancy, prescribed methadone. There are
Health (England) and
therapeutic alliance. It then moves recommendations include recommendations for monitoring
the devolved
administrations. (2007) on to describe various formal continuation of buprenorphine, those on high doses and with risk
Drug misuse and interventions including support psychological interventions for factors for QT interval prolongation.
dependence: UK for contingency management with cocaine users, advice on smoking This will no doubt stimulate much
guidelines on clinical plans to provide guidance on cessation and alcohol use. discussion of how to implement this
management.
implementation. There are Breastfeeding should be encouraged, on a practical level within services.
London: Department of
recommendations for mutual aid/self except when the mother uses This is just a brief summary of our
Health (England), the
Scottish Government, help and brief interventions. Special cocaine, crack, or high dose reading of the document and
Welsh attention is given to those who have benzodiazepines. highlights some points of particular
Assembly Government comorbid mental health problems Co-morbidity between mental interest. The new ‘Orange Book’ will
and Northern Ireland with advice on evidence based health problems and substance no doubt, deservedly, become the
Executive
treatment and reference to the NICE misuse are discussed. There is advice backbone of our clinical practice; it is
guidelines for anxiety and depression. on joint working between mental a credit to the working group
2National Treatment
Agency (2003) Chapter 5 gives guidance on all health and substance misuse teams. members and contributors. As
Injectable Heroin aspects of pharmacological treatment Separate provision of services is clinicians it is now our job to ensure
(and Injectable for drug misuse. The process of recommended for younger substance the information contained in the
Methadone): Potential starting, maintaining, supervising and misusers; those requiring long term guidelines is cascaded to all members
Roles in Drug
stopping treatment is discussed, but treatment should be managed by of our teams and enable services to
Treatment. London:
National Treatment particular attention is paid to children and family health, social and change and develop delivering
Agency. methadone and buprenorphine. Of education services. evidence-based care.
6SCANbites | WINTER 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS
Pain and Substance Misuse:
improving the patient experience
Pain and substance misuse In this context the British Pain clinicians – recognising that many
commonly occur together and Society published its consensus general clinicians will be dealing with
have the potential to present document for consultation in 2006.3 these clinical challenges. Section 1
challenges to clinicians. It is well The document, developed by a addresses the physiological and
recognised that pain patients treated group of professionals from pharmacological mechanisms
appropriately with opiate addiction and pain management, associated with pain and substance
medications can develop behaviours presents a coherent, evidence-based misuse and outlines the treatment
more commonly seen in substance and patient-centred framework for approaches recommended in the
misuse – such as ‘doctor shopping’ clinicians. It acknowledges the lack UK. Dr Brian Kidd,
Consultant
or drug-seeking – which clinicians of a strong evidence base despite the Section 2 explores the legal
Psychiatrist and
find difficult to address.1Substance prevalence of both pain and frameworks which regulate medical Senior Lecturer,
misusers often experience illnesses substance misuse in the general treatment as well as exploring the NHS Tayside
associated with pain with up to 37% population. potential implications of the Substance
of patients on methadone Shipman Inquiry. Misuse Services,
Tayside Primary
programmes experiencing significant Key messages Section 3 covers assessment in detail
Care NHS Trust
pain.1These conditions affect quality A key message of the document is – emphasising the need for doctors
of life and are appropriately treated the complexity of the pain to approach patient care objectively
with opiate analgesics, but general experience. It is acknowledged that and to avoid making moral
clinicians, whose judgement can be pain is affected by a range of judgements or assumptions. It is
coloured by the presence of biological, psychological and social emphasised that good clinical
substance use problems, may factors. These factors must all be practice involves comprehensive
struggle to treat these conditions taken into account when assessing assessment using a model including
consistently and effectively.2 and treating pain and substance biological, psychological and social
misuse. The role of the clinician is factors. Readers are directed to
scrutinised closely. It is current national guidance
emphasised that clinicians documents for more detail.
must be aware of their Section 4 considers likely clinical
prescribing presentations and the practical
obligations. They solutions which will help address
References
must have them. In particular it discusses
knowledge of the aspects of service organisation and 1Weaver M., Schnoll
biophysiological pathways of care between general S. (2007) Addiction
mechanisms and specialist services. Section 5 issues in prescribing
opioids for chronic
their prescribed presents the specific issues around
non-malignant pain.
treatments are palliative care, labour and prisons –
Journal of Addiction
affecting as well clinical areas which add to the Medicine 1(1): 2-10
as awareness of the complexity of this patient group. 2Rosenblum A,
legal frameworks Joseph H, Fong C,
within which they work Conclusions Kipnis S, Cleland C,
Portenoy R (2003)
when prescribing controlled This document is a welcome
Prevalence and
drugs. Clinicians are addition to the clinical guidance
characteristics of
reminded of the potential for available. It takes a position which chronic pain among
prescribed opiates to be acknowledges that pain and chemically dependent
misused or diverted. substance misuse are common and patients in
will therefore present in many methadone
maintenance and
Structure clinical settings. It also recognises
residential treatment
The document is that these conditions can be facilities. JAMA
structured to meet challenging for clinicians. The key to 289(18) 2370-2378
the needs of all success is access to valid information 3 The Pain Society
and the delivery of care within a (2006) Pain and
Substance Misuse:
coherent and comprehensive
improving the patient
framework delivered by objective
experience. The Pain
non-judgemental clinicians. Society, London.
SCANbites | WINTER 2007 7
REVIEWS
recommend baseline screening for cardiac
risk or elaborate on what constitutes
sufficiently “careful” monitoring.9This
leaves it to individual clinical judgement
and is dependent on the cardiology
competencies of the clinician in accurately
assessing the risk/need to screen, and the
resources available. Certainly many
addiction services do not have adequate
physical examination facilities and few
have an ECG machine or indeed medical
staff who can confidently interpret ECG
recordings. However it is clear that QT
interval determines the risk of arrhythmia,
Cardiac side effects of opioids: How should that risk is increased in the elderly,
females, those on antidepressants or
clinicians assess and manage the risk?
antipsychotics, those concurrently using
sedatives or alcohol and concurrently
Dr Judy Myles, Senior Lecturer in Addictive Behaviour and Consultant Psychiatrist, treated with antiretrovirals. One
St George’s, University of London and South West London and St George’s NHS Trust, suggestion has been that we ask GPs to
and SCAN Consultant Psychiatrist Policy Advisor.
conduct ECG screening on patients being
referred, but whether that is a practical
The major identified cardiac risk for that all the research in this field is being solution has yet to be tested and would
the opiate dependent patient is that generated by cardiologists, not addiction not allow for screening of the highly
References of QT interval prolongation, that specialists. vulnerable self-referrals to direct access
1Lipski, J., Stimmel, B. & being an imprecise indicator of the risk for Since both methadone and services.
Donoso, E. (1973). The effect of ventricular tachycardias, and Torsades de buprenorphine have been recommended There are therefore several questions
heroin and multiple drug abuse Pointe, the fatal endpoint of ventricular by NICE for the treatment of opiate that need to be explored to allow us to
on the electrocardiogram. Am
tachycardias. QT prolongation has already dependency7, clinicians now have a best treat patients coming to our services:
Heart J, 86: 663-668.
led to the withdrawal of a variety of choice of pharmacotherapy according to (cid:129) Do we need to screen all new patients
2Maremmani, I., Pacini, M.,
Cesaroni, C., Lovrecic, M., et psychotropic medications, e.g., patient need, but how do they make an and assess cardiac risk when making
al., (2005). QTc interval thioridazine, and the long acting synthetic informed choice? prescribing choices?
prolongation in patients on opioid, LAAM. The current MHRA guidance8, (cid:129) Do we need to screen all patients
long-term methadone
There is evidence, some dating from incorporated in the recently updated prescribed methadone at regular
maintenance therapy.
European Addiction Research, as early as 1973, that methadone Clinical Guidelines 9, recommends that intervals?
11(1):44-49. prolongs the QT interval in patients on “patients with the following risk factors (cid:129) Should we prospectively screen patients
3Krantz, M. Lewkowiez, L., methadone maintenance.1Methadone is for QT interval prolongation be carefully at baseline to determine the risk in our
Hays, H., Woodroffe M., et al.
a potent inhibitor of HERG (human ether- monitored whilst taking methadone; heart treatment population?
(2002). Torsade de pointes
associated with very-high-dose a-go-go) potassium channels and there or liver disease, electrolyte abnormalities, (cid:129) Should we work more closely with GPs
methadone. Annals of Internal have been numerous studies, mainly concomitant treatment with CYP 3A4 in thorough health screening of opiate
Medicine. Vol. 137(6): 501- retrospective case note studies, of the inhibitors, or medicines with the potential addicts and would they be willing to
504.
correlation between methadone dose and to cause QT interval prolongation. In conduct such screening?
4Ehret, G., Voide, C., Gex-
QT interval.2-4There was no correlation addition, any patient requiring more than (cid:129) Should addiction specialists focus on the
Fabry, M., Chabert, J., et al.
(2006). Drug-induced long QT found in the first of these studies but one 100 mg methadone/day should be closely physical health risks more generally in
syndrome in injection drug was found in the second and third. All monitored.” addicted patients and if so how is that
users receiving methadone: researchers recommended baseline ECG Given the profile of patients now to be resourced?
High frequency in hospitalized
to identify those at risk prior to initiating presenting to addiction services for (cid:129) Should our Trusts be required to provide
patients and risk factors.
Archives of Internal Medicine, treatment. treatment, with poly substance misuse us with ECG machines and update our
166(12):1280-1287. Given that the majority of substitute including alcohol, which also causes QT competence in interpreting the
5Krantz, M., Lowery C., prescribing for opiate dependency in the prolongation, the rate of co-morbidity recordings or should we request ECG
Martell, B. et al. (2005). Effects UK is with methadone, there are with psychiatric disorders, particularly machines that provide a report?
of methadone on QT-interval
questions about how to accurately assess mood disorders, some requiring (cid:129) Should we be conducting research into
dispersion. Pharmacotherapy.
25(11):1523-9. cardiac risk and make prescribing antidepressants, again increasing the the cardiac consequences of
6Baker, J., Best A., Pade P. & decisions that are pertinent for prescribers. potential for QT prolongation, and the opiate/opioid dependency?
McCance-Katz E. (2006). Effect This is particularly so since buprenorphine significant numbers with liver disease, it is (cid:129) Should we seek more resources to
of buprenorphine and
is not a potassium channel inhibitor, unlike apparent that we may be dealing with a examine patients properly, probably
antiretroviral agents on the QT
interval in opioid-dependent methadone or LAAM, and therefore has population at high risk. including ECG machines that provide
patients. Annals of Pharma- been demonstrated not to affect the QT Additionally we do know that a reports?
cotherapy, 40(3): 392-6. interval. Indeed, there is a case report of a percentage of the general population We also should now, with the evidence
7NICE (2007). Methadone & high dose methadone patient with suffer asymptomatic congenital QT and guidance available, be considering
Buprenorphine for Managing
Torsades de Pointe being successfully prolongation, which is more common in cardiac risk when making prescribing
Opioid Dependence. NICE
Technology Appraisals. transferred to buprenorphine with no women than men. But the population decisions. We should also be actively
8MHRA (2006). Current recurrence of cardiac complications.5 prevalence in the UK is unknown, seeking research funding, together with
problems in Pharmacovigilance, Baker et al (2006) prospectively monitored therefore the percentage of patients cardiology colleagues, to conduct
31:6. the QT interval in patients prescribed seeking treatment, who are at increased prospective studies of UK treatment
9Department of Health buprenorphine and the combination risk at baseline, is also unknown. populations to determine the risks and
(2007). Drug Misuse &
buprenorphine/naloxone and found no The current guidance recommends safest methods of substitute opioid
Dependence; Guidelines on
Clinical Management. QT prolongation6. It is also noteworthy “careful monitoring” but does not prescribing.
8SCANbites | WINTER 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS
On what evidence do we manage
suicide risk in patients with
alcohol problems?
Dr Julia Sinclair, Senior Lecturer in
Psychiatry and Honorary Consultant
Addiction Psychiatrist, Southampton
University and SCAN Consultant
Psychiatrist Policy Advisor.
Hazardous and harmful alcohol have attempted to re-engage with
use and alcohol dependence them.
have long been recognised as So what does this mean in terms
risk factors in the pathway to suicide. of suicide prevention in patients with
There are a number of complex alcohol dependence?
interacting mechanisms by which this Some of the inquiry results need
might occur: to be interpreted with caution: they
Pharmacologically, alcohol is a are based on retrospective data
respiratory depressant; it therefore collected by clinicians who are not
increases the lethality of other similarly blind to the outcome for their
acting compounds, when taken together at toxic levels (e.g. methadone) patient; and it is not a case control study, so we cannot tell how commonly
Intoxication with alcohol increases behavioural disinhibition, resulting these factors also occur in patients who don’t go on to die by suicide.
in an increased likelihood of acting on an impulse, image or thought that Good alcohol and drug histories are not routinely recorded in clinical
might be resisted in the sober state. notes and so these figures may underestimate the prevalence of alcohol
Alcohol promotes depressive symptoms, which raise suicide risk, by misuse, and the impact it has on suicide risk. A previous case-control study
enhancing negative ruminations, leading to a sense of low self-esteem and of suicide in psychiatric patients showed that suicide rates were reduced in
hopelessness. These feelings are often amplified by the impact that patients with known alcohol problems, but that the rate of recorded alcohol
continued drinking has on personal and social failures, increasing isolation problems was low, suggesting that the risk might be increased in those
and loss events (relationships, job, home etc). All these are independent whose alcohol use was not recognised.2
risk factors for suicide and so the overall burden of risk is high. The NCISH reported that at final contact with services the immediate
Finally, inadequate access to good treatment provision may further risk of suicide was assessed as low or absent in 86% of patients, yet
increase feelings of hopelessness and worthlessnessin those who have lost recommendations from the inquiry include:
all sense of self-efficacy. (cid:129) Community services to have an assertive outreach team
At a population level, suicide rates in England and Wales have fallen (cid:129) Written policies regarding the management of patients with dual diagnosis
from 11.95 per 100,000 in 1997 to 10.43 per 100,000 in 2004.1 However, set (cid:129) Clinical staff receive training in the management of suicide risk at least
against this trend is the fact that all the indicators for alcohol consumption every three years
and hazardous drinking are increasing. Given the well established links However, in terms of patients with alcohol problems, who are often
between alcohol and suicide what impact might this have on the trends in excluded, either explicitly or implicitly, from acute adult services, the main
suicide rates? areas for suicide prevention are likely to come from addressing the problem
The most recent report on avoidable deaths from the National at a number of levels:
Confidential Inquiry into Suicide and Homicide (NCISH) by people with (cid:129) Reducing levels of drinking in the population, thereby reducing the
mental illness reports on five years of data (2000 – 2004).1 proportion that drink hazardously - the least likely course of action, but
The NCISH audits the suicides of current or recent patients of mental the one most likely to be effective!
health services. Recently, annual rates have remained unchanged at (cid:129) Adequate recognition and treatment of depression and alcohol misuse in
approximately 2.9 per 100,000. Given the reduction in the general primary care
population rates, this equates to a relative increase (24 to 29% of all (cid:129) Thorough assessment of alcohol use in all psychiatric patients
suicides) in the patients who were known to mental health services. (cid:129) Dynamic risk assessment and awareness of protective factors for patients
This rise might be accounted for by the relative reduction in suicides at known to the service.
a population level, or it may represent an increase in the suicide risk of
patients known to secondary care services. We are unlikely to prevent all suicides in patients with alcohol problems, but
Within the NCISH, patients with an affective disorder as their primary a good therapeutic relationship with those at very high risk as well as
diagnosis constitute the largest group (46%); those with a primary diagnosis promoting population strategies for those at lower risk is likely to have the
of alcohol dependence constitute only 8% and drug misuse in only 3%. greatest impact.
However, in patients of all diagnoses who died by suicide, a history of
alcohol misuse was noted in 44%, drug misuse in 30% and both alcohol and
drug use in 21%. Suicide rates in those with severe mental illness (requiring References
inpatient care) are particularly high in the first three months following 1 Avoidable deaths- five year report of the national confidential inquiry into suicide and homicide by
people with mental illness. www.medicine.manchester.ac.uk/suicideprevention/nci/
discharge from hospital. In this group 47% were noted to have a history of
2 King E, Baldwin DS, Sinclair JMA, et al. (2001). The Wessex Recent Inpatient Suicide Study, 1: Case-
alcohol misuse.
control study of 234 recently discharged psychiatric patient suicides. British Journal of Psychiatry; 178:
Of the 491 patients with a primary diagnosis of alcohol dependence 531-536.
reported, 60% were unemployed, and 68% had an additional psychiatric
disorder. They were more likely than those with other diagnoses to have (cid:129) Declaration of interests. Julia Sinclair is a member of the external advisory board to the National
missed their final appointment, and it was less likely that services would Confidential Inquiry into Suicide and Homicide
SCANbites | WINTER 2007 9
TRAVELLING FELLOWSHIP SPRS
How does addiction treatment differ on Substance misuse
opposite sides of the pond?
AMERICANand European prison
In May of this year Specialist Registrar Dr Billy Boland therapeutic sessions as a key to systems have been faced with large
went to the USA, courtesy of a SCAN Travelling psychological processes in number of mentally ill prisoners. There
Fellowship scheme, to visit three addiction centres. treatment. are twice as many prisoners with mental
health problems in American prisons
THE VISIT Yale University, New Haven than there are in mental health
A trip to Yale in New Haven, hospitals.1One wonders whether
University of Connecticut (UCHC) and allied Connecticut formed the close of prisons are replacing mental hospitals.
clinical services my journey. This was hosted by Prof Stephanie The lifetime prevalence rate of mental
The first centre I visited was hosted by Prof Tom O’Malley, a psychology professor prominent in the disorders including substance misuse
Babor. I had the chance to see two contrasting alcohol research field. I was invited to visit the disorder is 71% in England.2Large
clinical services here. The Blue Hills Substance Misuse Substance Abuse Treatment Unit (SATU), a variations exist with regard to discovered
service is a State funded facility in Hartford, community team for people with substance misuse prevalence rates of specific mental
Connecticut and operates a multidisciplinary case problems. What was particularly interesting about disorders; however 40% of all prisoners
management model that has remarkable similarity this clinic was the close relationship it had with the appear to have a substance misuse
to specialist treatment services I am familiar with in University and how research was integrated into the disorder. Of 125,000 prisoners who are
the UK. clinical services. Many of the patients who accessed sent to prison (on remand or after
Forty minutes from Hartford lies Middletown and this facility would be recruited into a clinical research sentence) in England and Wales, 60,000
the STAR programme, a state-funded inpatient trial and this was possible as a result of the unique are problem drug users and 40,000 have
treatment centre for women only. The service configuration of the clinic. severe alcohol dependence.
centred on an intensive schedule structured on a I also went to the Veterans Association Medical A quarter of inmates start using
framework of a 12 step programme with group and Center (VA) in New Haven. The configuration of heroin for the first time in prison and
individual sessions throughout the week and a services here are very similar to the VA in Providence. about 2-4% inject in prison, 16% have
contingency management plan running for the Both SATU and the VA had personnel working in injected, 55% share needles.3Cannabis
course of the stay. clinical services and employed by the University and cocaine use is also common. In
There is a strong portfolio of addiction research at which seemed to encourage an active integration relation to self inflicted deaths in prison
UCHC. The focus here is upon public health between research and clinical services. The service population, 72% had a history of mental
interventions and clinical trials. I met with researchers included both community and inpatient treatment disorder and the commonest diagnosis
who work with Prof Babor and learnt about some of facilities. was drug dependence, about 27%.4
their recent studies on brief interventions. The team Drug withdrawal on admission may be a
were particularly interested in translating the Since my return…. causative factor for self harm. The risk of
promising outcomes from brief interventions into Since returning to the UK I have had time to reflect death during the first week after release
practice and were looking at what was required to on my short tour of services in the US. I had gone is 40 times higher than expected in this
make delivery of the interventions sustainable. with expectations of encountering marked contrast population, usually as a result of opiate
in aspects of addiction treatment and research, but I overdose.5
Providence, Rhode Island was struck more by the similarities rather than the Treatment of drug misusing
This part of my trip was convened by Prof Peter differences. The US healthcare system is complex. I prisoners is therefore very important,
Monti. I spent a day at the Veterans Hospital in thought I broadly understood its ethos and partly also because many prisoners have
Providence. Compared to much of the US health mechanisms before I visited, but the trip challenged no other contact with treatment
system, the Federal Government invests heavily in these preconceptions and really gave me a flavour of services. There is also evidence that
services for veterans, and it seems that some of the how difficult it must be for service users to negotiate heroin using prisoners treated with
most significantly developed addiction services treatment for themselves. methadone throughout their
cater for this population. For both community Although I visited a range of established clinical imprisonment were less likely to die
and outpatient services, a 12 Step approach services, accessing treatment remains a problem for after release or to come back into
has traditionally been the foundation of large sectors of the population. My impression is prison. The treatment of prisoners with
treatment provision. However at the that in this insurance based health economy it is not substance misuse problems may be
time of my visit the team were necessarily the most comprehensively insured that useful in bringing hard to reach drug
working towards diversifying have the best opportunities for addiction treatment. users into treatment, reducing overdose
their treatment strategies. I heard stories that in recent years insurers were rates during and after imprisonment,
The university has a becoming much more involved in discriminating reducing injecting and blood-borne virus
significant portfolio mechanisms of treatment, and being discerning in infection, and preventing recidivism.
of addiction which types of treatment they will fund.
research, with Crucially, this was manifest through limiting Detoxification Unit in HMP Durham
a strong focus treatment provision based upon comprehensiveness The substance misuse treatment service
on of insurance cover. Clinicians frequently felt that within HMP Durham has been
psychology. although some insurers were interested in the established for four years. It provides
Of note are quality of treatment, it was absolute cost, rather comprehensive and effective substance
studies of than cost effectiveness that appeared to be the chief misuse services to the prison population
combination driver. in partnership with other healthcare,
psychological Thanks very much to SCAN and my hosts for this Criminal Justice Services (CARAT, Drug
treatments for trip. It certainly broadened my understanding of Intervention Programme and Probation),
adolescents and other addiction treatment and challenged my ideas of Community Drug Treatment services,
work looking at the how it should be provided. Please see the SCAN social care providers and the prison
ingredients of a website for my full report. service.
10SCANbites | WINTER 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS