DDN April 2017

‘We need to understand the risks of Xanax and the culture behind it’

It’s never easy to weigh up the level of drug risk based on America – remember the hysteria over crystal meth a few years ago, with drug services in the UK gearing up for the scale of devastation seen in some communities of the US? But with evidence of cases multiplying and including many young people, we need to understand the risks of Xanax (alprazolam) and the culture behind it. Anxiety is starting to be well documented, particularly among young people, and Xanax’s link with celebrity makes it difficult to deter experimentation with the drug. Kevin Flemen’s article explains the nature of the threat and what to look out for.

Throughout the rest of this month’s issue we talk a lot about prison – including the perspective of a service manager, who until recently was working at the frontline of prison substance misuse services. He feels compelled to share experience of clients being rushed through very intense treatment programmes, and of many opportunities for holistic interventions being dismissed or unsupported.

We can see the results of life-changing interventions through Addaction’s Trans4orm programme and RAPt’s thriving apprenticeship programme – both of which have the activities that are essential to self-sufficiency and self-esteem at their heart, and demonstrate results of properly supported initiatives. The other huge opportunity in investing in engagement with those in the criminal justice system is, as Charles Gore reminds us in relation to hepatitis C, to offer life-saving inventions and ‘send people out of prison better than they went in’.

Claire Brown, editor

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Time to talk

Talking therapies are among the many options that should be offered alongside OST, says Clive Hallam.

Recently, a post on social media considered the question of whether talking therapies added any value to people who were committed to opioid substitution treatment (OST) on a long-term basis.

National data shows the group of long-term, committed recipients of OST is growing, month on month, across the country. However it isn’t clear whether this is because of a personal desire for, and commitment to, long-term OST, or because people have been stranded on repeat prescriptions, with minimal contact from a practitioner – both conditions exist.

Certainly, the figures correspond with cohorts of individuals who have long careers of substance use and are highly complex, and this brings into question the ability of current treatment delivery to respond appropriately.

People may commit to long-term, or lifetime, treatment for a variety of reasons, objective and subjective. There may be a clear clinical need in certain cases; however, people also resist change and avoid challenge.

Pharmacological interventions are comparatively well researched and evidenced, with the effects quite easy to predict and observe. Therapeutic doses can also be achieved relatively quickly, enabling an individual’s physical circumstances to be moderated effectively. But the effect of those doses may be more than we envisaged in terms of affecting someone’s ability to interact, and some researchers have linked methadone with significant cognitive impairment.

By comparison, talking therapies depend almost exclusively on the specific relationship between the person and the practitioner to be effective – the emotional context and connection, and a desire to respond or change dynamically.

NICE considers that few talking therapies have the evidence base to warrant their use, particularly in this client group, preferring contingency management to support people in OST. But if a person’s ability to reason is adversely affected by opiate use, might this be the primary reason for the failure of talking therapies – and should this be factored into decisions about treatment?

Other issues also come into play here. At what point has the impact on the individual been measured? How resistant is the person to talking? Do they regularly miss appointments believing they won’t benefit from them? Do they present on the autistic spectrum? Can they get their prescription and side-step psychosocial altogether? All these questions are as relevant for the long-term methadone patient as for the person just starting treatment, and make the success of talking therapies difficult to qualify.

What could be of more importance is a person’s access to meaningful use of time, whether to pursue hobbies, learning, look for volunteering or work opportunities, or otherwise be diverted from their established courses of action and interaction. There is a clear role here for mutual aid, residential rehabilitation and therapeutic communities – yet aren’t these types of talking therapies?

Nicholas Christakis (Connected, Harper Press, 2009) speaks of changing people’s outlooks and cultural position. He argues that individuals in a concentrated network naturally exhibit its predominant emotions, actions and cultural perspectives. To effect positive and sustainable change, exposure to ‘integrated’ networks, with a range of views and cultural stances is necessary. Mutual aid and recovery communities are excellent gateways to such networks; concepts such as time-banking and co-production enable individuals to explore their aspirations, skills and knowledge. This is supported by the observations of William L White in the United States.

Experience across the country has demonstrated the value of running such programmes side by side, enthusing people to be involved in activities such as equine therapy, working in the countryside, and time-banking with local communities, at the same time as receiving OST.

Fundamental to this approach has been psychosocial support, providing an opportunity to discuss issues, events and concerns in an encouraging, supporting and enabling environment. Keyworkers and psychosocial practitioners can have a crucial role to play in enabling individuals to experience and understand their worth in such environments.

Any viable system must offer a range of interventions that present the most options for pursuing a full life. If this isn’t also given to lifetime methadone patients, including the option to stop OST, how can they make an informed judgement?

During my career as a commissioner, I’ve resisted the concept of tendering every few years to find the ‘best response’, the ‘most economically advantageous tender’ and the ‘best provider’ for the task. Treatment provision is fundamentally different to purchasing stationery and, while there’s a place for market testing, it can be detrimental to long-term care and outcomes that celebrate the best in individuals.

Commissioning is an art form, working with people in treatment, families and communities, providers and partners to ensure maximum opportunities are identified, explored and delivered. It is about seeking solutions that are sometimes the best, sometimes wrong, often pragmatic, but always looking to offer individuals the chance to choose something that is right for them. That may be a lifetime prescription – equally, it may be a detox through a personal realisation after years that there’s something more to life. We shouldn’t define either aspiration, or delivery, by saying one way or another is the only way.

‘The best treatment system provides a spectrum of interventions… there isn’t one size that fits all.’

The best treatment system provides a spectrum of interventions for those wishing to explore them. While we live in a time of ‘austerity’ there has to be sufficient funding in the system to adequately care for people through prevention, harm reduction, early intervention, structured community and residential interventions and aftercare – and, underlying it all, mutual aid and positive social networking. The question should be, how do we employ all interventions in a way that enables individuals to achieve their highest potential, benefiting themselves and those around them. There isn’t one size that fits all.

Our current system of drug treatment, begun under the tenets of harm reduction, remains predicated on the criminal justice arguments of the early 2000s, which unfortunately hides the more relevant harm reduction message. People do not need to be placed on methadone for life and until this argument changes, options for recovery will remain limited, with interventions responding in part only to the needs of the individual.

The narrow argument concerning what is right for individuals needs to be consigned to history. Individuals, commissioners and providers must move to one that liberates individuals to make the decisions that are right for them – governed by facts, aided by considered support, and revelling in aspiration and recovery. There are many routes to recovery; as many as there are people who need them.

Clive Hallam has worked in the sector for 13 years as a commissioner and consultant

Reflection of hope

With their roots in harm reduction services, Kaleidoscope Project provide both community and residential drug and alcohol treatment. Their new 20-bed detoxification unit in Merseyside continues their tradition of providing life-changing support for every individual. 

Birchwood Residential Treatment Centre

‘For the last 49 years Kaleidoscope has worked with some of the most marginalised clients with the highest need,’ explains chief executive Martin Blakebrough. So when the opportunity came up to incorporate Arch Initiatives into the Kaleidoscope family and add to the residential detox facilities at Birchwood House, it seemed a logical step for the organisation.

The move was never part of an attempt to become ‘the next big player’, Blakebrough emphasises, but rather a natural progression for Kaleidoscope. ‘Running Birchwood provides a chance to develop a bespoke inpatient treatment facility. A place that can support a broad range of clients, including those with complex needs.’

To achieve this, it was important to have the right team in place, which Blakebrough is confident about. ‘In Kaleidoscope executive lead, Rondine Molinaro we have someone who is passionate and knows what is required, but is looking to learn from the latest research and thinking,’ he says. ‘And our clinical team of full-time NMPs and substance misuse nurses working alongside both a GP and a consultant psychiatrist allows us to accept people with significant difficulties.’

The unit at Birchwood comprises 20 single occupancy bedrooms, including three on the lower floor for those with specific requirements or mobility issues. The service is for both men and women, including pregnant women and those with complex needs. The newly refurbished rooms and the superb onsite catering help to create that ‘home away from home’ feel that provides the right therapeutic atmosphere for clients’ treatment.

Staff provide treatment tailored to the needs of the client

‘Within Birchwood we offer a flexible, individually tailored treatment regime, by carefully screening all potential admissions to ensure that we can safely assist the withdrawal of substances,’ explains Birchwood’s clinical director, Dr Mohan De Silva. ‘Medical screening is done by a doctor. We look at GP medical history, previous hospital letters, any previous detox experiences, current medication and recent blood investigations. Having as complete a history as possible enables us to build a picture of the health of the patient and ensure their safety while at Birchwood.’

A range of programmes are offered for opiates, NSPs, stimulants, prescription medications and alcohol. These include a rapid five to seven day detox programme for individuals requiring urgent detoxification, a three to four day stabilisation and detoxification initiation that will be continued in a community setting, and both standard and complex detoxification programmes that can last between seven and 21 days, depending on the needs of the client. In addition, alternative regimes for alcohol detoxification can be offered, which are non-benzodiazepine based.

‘Having an experienced clinical team on site allows Birchwood to offer this range of interventions,’ says consultant psychiatrist, Dr Julia Lewis from Pulse Addictions. ‘As well as working with them to develop their clinical policies and procedures, I provide regular clinical supervision to their permanent team of experienced nursing staff who are committed to continuous service improvement. The aim of everyone involved in Birchwood is to ensure that the treatment on offer is safe, effective and meets the needs of the client.’

A medical team is based on site

The client-centred approach goes beyond detox, and a range of mutual aid packages are offered, including 12-step, SMART Recovery, and access to the Life Ring service. In addition a weekly health clinic is available to identify wider healthcare issues and other chronic conditions that may have been masked by a client’s drug taking.

The client-centred approach is something that Rondine Molinaro hopes to take beyond treatment provision to the running of Birchwood itself, with a long-term aim to transform it into a social enterprise. This would create the opportunity to provide a free detox space each month to someone who is unable to access funding through conventional means – ‘someone who may need another chance,’ she says.

Central to Kaleidoscope’s culture is an understanding that detox is not a miracle cure, and for many clients may be just part of their journey – an ethos underlined by equipping clients with relapse prevention training, RPM medication, and take-home naloxone on leaving the facility.

What is very clearly on offer at Birchwood is the opportunity for people to reset their lives and make fundamental changes. ‘While this is not a one-fix-wonder, hopefully it can inspire people to live life better,’ says Blakebrough.

Birchwood House residential treatment centre welcomes referrals from a range of clients including statutory, criminal justice and private clients. To find out more please contact executive lead, Rondine Molinaro on 07773 211461 or email enquiries@birchwoodtreatment.com

This article appeared in the April issue of DDN Magazine.

Trump administration to step up ‘war on drugs’

The US administration under President Donald Trump has signalled that it intends to intensify the ‘war on drugs’, with a return to 1980s-style prevention campaigns and the use of marijuana possession as a means to deport immigrants who don’t have proper documentation.

The direction is in contrast to that of the Obama administration, which steered prosecutors away from pursuing low-level drugs offenders, while one of President Obama’s final acts in office was to commute the sentences of 330 prisoners. The ‘vast majority’ of these were serving ‘unduly long sentences for drug crimes’, the White House said (DDN, February, page 4).

‘Let me be clear about marijuana,’ said homeland security secretary, John Kelly. ‘It is a potentially dangerous gateway drug that frequently leads to the use of harder drugs.’ The US Immigration and Customs Enforcement department (ICE) would ‘continue to use marijuana possession, distribution and convictions as essential elements as they build their deportation/removal apprehension packages for targeted operations against illegal aliens,’ he stated.

While marijuana remains illegal under US federal law, eight states have now legalised the drug for adult use – including five which did so at the time of last year’s presidential elections (DDN, December 2016, page 4) – and almost 30 states have medical marijuana laws. ‘It’s outrageous to think that anyone following medical advice under state law would be subject to deportation,’ said policy manager at the Drug Policy Alliance’s Washington-based office of national affairs, Jerónimo Saldaña. ‘The Trump administration has signalled its desire to use the drug war as a tool to persecute immigrants.’

The announcement follows a speech last month by the US attorney general, Jeff Sessions, in which he praised the drug prevention campaigns of the 1980s and ’90s and stressed the need to prevent ‘people from ever taking drugs in the first place’. Treatment often came ‘too late to save people from addiction or death’, he said.

‘Too many lives are at stake to worry about being fashionable,’ he stated. ‘I reject the idea that America will be a better place if marijuana is sold in every corner store. And I am astonished to hear people suggest that we can solve our heroin crisis by legalising marijuana – so people can trade one life-wrecking dependency for another that’s only slightly less awful. Our nation needs to say clearly once again that using drugs will destroy your life.’

President Trump is also expected to appoint a hardline drug war advocate, Tom Marino, as the next head of the Office of National Drug Control Policy – the country’s ‘drug czar’. Marino strongly supports a ‘punitive, 1980s approach to drugs’, says the Drug Policy Alliance, which called him a ‘disastrous’ choice. ‘Our nation needs a drug czar that wants to treat drug use as a health issue, not someone who wants to double down on mass incarceration,’ said its director of national affairs, Bill Piper. ‘The American people are moving in one direction and the Trump administration is moving in another. There are few hardcore supporters of the failed war on drugs left, but those that are left seem to all be getting jobs in the administration.’

Jeff Sessions’ speech is at www.justice.gov

Stuck in the system

New treatment for hepatitis C has opened up massive opportunity for all-round health gains that we are just not taking, hears DDN.

We need to look at syndemics, said Charles Gore – when a set of linked health problems such as hepatitis C, drug and alcohol issues, mental health and homelessness interact to increase the person’s poor state of health and chances of disease. As chief executive of the Hepatitis C Trust and vice chair of the Hepatitis C Coalition, Gore was speaking to the Drugs, Alcohol and Justice Cross-Party Parliamentary Group about access to treatment.

Charles Gore: ‘Treating the prison population represents a huge opportunity… one area where you could send people out of prison better than they went in.’

In Scotland, treating people who injected drugs for hepatitis C had reduced death rates for this group by 50 per cent – ‘so treating hepatitis C might be a way of breaking this syndemic apart’, he said.

People who were treated were more motivated to address other factors, he explained, ‘so hep C treatment has a bigger effect than you might think’.

There had been ‘great breakthroughs’ in hep C drugs, which had a 95 per cent cure rate and were very tolerable to take (compared to previous treatment, which took a year and was ‘very unpleasant’) – ‘so we’re in a new era here’, he said.

In England there were around 160,000 people with hepatitis C, but a budget to treat only 10,000 of them. Treating all of them, at a cost of around £200m, would be ‘a lot of money – but not compared to other disease areas’.

The first year of new drugs had seen an 11 per cent decrease in mortality and a 50 per cent decrease in demand for liver transplants. ‘The gains in terms of health are enormous,’ said Gore.

The reasonably short course of eight to 12 weeks for the new treatment also meant there could be a big impact on treating people in prison.

Despite this, hep C testing and treatment levels in prison were low and prevention strategies ‘quite muddled and not homogenous across the prison estate’, failing to tackle the common transmission routes of shared needles, tattooing and sex.

In the community, there were wide variations in treatment strategy throughout the UK. In Wales, health boards had put money aside but could not find enough people to treat, while in England, a cap on numbers was stopping many people from accessing treatment. ‘Some areas of the country have massive waiting lists, but some are running out of people,’ said Gore. Financial incentives for finding and following up people after treatment also risked making low priority cases of those who were hard to follow up – ie the drug-using population.

The NHS was investigating procurement deals with pharmacies, and Gore explained that the Hepatitis C Trust had a preferred model of ‘one price for an unlimited amount of treatments, so there would be a great incentive to treat as many people as possible. At the moment, the system disincentivises treatment and the cap disincentivises testing.’

Treating the prison population represented a ‘huge opportunity’, Gore believed – ‘It’s one area where you could send people out of prison better than they went in.’ There were 10,000 people in prison with hepatitis C, and ‘if we took this population and treated them we could make a big difference’.

The current cap and rationing system did not prevent members of the population with advanced liver disease from being treated as a priority. The problem was for those who had to wait two years – ‘and this assumes you’re in services,’ he explained. ‘But you may be in prison. You may be a person who might not be in touch with services again, and when you do, you may have liver cancer.’ Prison might be the only chance you have to treat them, so we were missing a significant public health opportunity, he said.

Gore also underlined ‘the tremendous importance’ of linking with people who are released from prison, who might be part way through treatment. ‘If we concentrated on prisoners’ health, we would have a much better chance of improving their chances.’

The parliamentary group’s discussion reflected PHE and NHS England’s need to work together on a hep C prevention strategy, but there was concern that ‘fragmented commissioning’ was hampering efforts, with costs falling in different parts of the system and no ‘strategic flow’ between them.

‘There’s a lot of joining up to do,’ said Gore. ‘People who spend and people who gain are different people.’


Under pressure

The celebrity craze for stress pills is even reaching schoolchildren – should we be concerned? Kevin Flemen looks at the risks and availability of alprazolam, branded as Xanax.

A friend of mine in Hackney was recounting a recent case involving the death of a child at her daughter’s school. While the inquest results were still awaited, it appeared the death may have involved alprazolam. When I voiced some surprise at this drug being a factor, my friend said: ‘All of my daughter’s friends are going on about Xanax. It’s really the thing at the moment.’

Xanax is the brand name of the benzodiazepine alprazolam. It is highly potent – some 20 times the strength of diazepam (Valium) – with a medium duration of effect and a half-life of around 12 hours. It is widely prescribed in America with claims that it is now the number one prescribed psychiatric medication. Most legal use in the UK is from private prescriptions as it is not prescribed on the NHS, but it is also available via the dark web.

Over the past few years, most UK reports of alprazolam have referred to it as a cut in heroin rather than a significant drug in its own right. Norwich police warned of alprazolam in heroin back in 2004, and in the more recent heroin ‘drought’ around 2010, reports circulated of orange-tinted heroin linked to overdoses.

Historically, the most popular benzodiazepine in the UK has been diazepam, which was frequently diverted from legitimate prescriptions. As prescribers were repeatedly reminded about the need to address widespread over-prescribing, people seeking sedation have had to resort to looking elsewhere.

Some injectors turned to temazepam, albeit with disastrous health consequences following the intro­duction of Gelthix capsules intended to deter injecting.

Pregabalin and gabapentin increasingly became the prescribed drugs of choice, and workers and peer educators reported an increase in ‘pregabs’ as a core drug of polydrug use – initially in custodial settings and then in community settings too. ‘It’s like sciatica is a catching condition,’ commented a prison drugs worker on a training course, noting ruefully how many prisoners presented to the medical team complaining of neuropathic pain in the hope that it would result in a pregabalin prescription.

Further afield, online pharmacies represented a ready source of tablets sold as diazepam. Overseas suppliers sold it in the form of blue pills – some genuine, but others containing a range of compounds or none of the drug at all. Canny consumers became increasingly wary of purchasing diazepam from such sources.

The explosion of novel psychoactives brought with it the advent of numerous novel benzodiazepines, includ­ing phenazepam, etizolam and flubromazepam. These worked, and were cheap and widely available. Rather than seeking dwindling NHS prescriptions or chancing random blue pills from Asia, more of the depressant market turned to these NPS benzodiazepines.

So back to Xanax. Is it becoming a ‘thing’ in the UK? If so, why – and to what extent is this likely to become a trend?

The drug has gained profile significantly. It has been linked to a number of high-profile celebrity deaths and continues to be associated with the media, earning mentions in music and film as well as appearing in many internet memes.

If diazepam is possibly a bit old and fusty, Xanax has become the sedating pill for those stressed by celebrity rather than mundanity. The school-age peers of the friend I mentioned at the start had come to Xanax via its associations with American celebrities. It was fashionable.

In recent sessions with young people in a number of settings, I’ve been exploring awareness of Xanax. In one (albeit small) group of young people in Norwich, all had heard of it and they mentioned memes that they had seen.

Although alprazolam isn’t significantly prescribed in the UK, there’s good availability via the dark web. A search filtered for European suppliers returned 297 entries on Dream Market. By comparison, diazepam returned 391 entries. Costs varied significantly, but 200 x 2mg tablets (the equivalent of 4 x 10mg diazepam) worked out at around £1 a tablet. There is clearly no shortage of people offering alprazolam, with the product range including raw powder and pills in various strengths.

Increased restriction on other sedating substances could further encourage its use. The existing non-regulated benzodiazepines were all automatically covered by the Psychoactive Substances Act 2016 (PSA), reducing legitimate access to these compounds via head shops and online suppliers.

The ACMD has pushed for further regulation, suggesting they be made temporary class drug order (TCDO) drugs, with a view to later making them fully controlled drugs. However, the government has declined, arguing that this would reduce the capacity to control these drugs in custodial settings. Nonetheless, it is likely that all the novel benzodiazepines will be scheduled at some point in the future.

The ACMD and government are also concerned about the diversion of prescribed medicines, and the misuse of pregabalin is a key issue. Therefore it seems increasingly likely that this, alongside gabapentin, will be made a controlled drug in the coming months. So for anyone seeking non-prescribed sedation, the dark web and illicit markets will be the main source of drugs, and alprazolam is increasingly a feature. This will be especially true for people who have built up significant tolerance to benzo-type drugs pre-PSA, and who will need to cross-substitute with similarly strong benzos to stave off withdrawal. Someone with a 2g a day flubromazolam habit would probably need 80mg of diazepam for a similar effect.

A discussion on an NPS forum made a similar point, highlighting a red 5mg alprazolam bar on the market, saying: ‘There are now vendors based in the UK producing their own Xanax bars for our market… there’s one in particular that has just this week come out with red bars containing 5mg alprazolam. These are pressed and sold in the UK. I do not think it is a coincidence that this is happening right after the Psychoactive Substances Act has come into force. No one with a clonazolam habit is going to get much out of diazepam after all…

‘This could be the start of an interesting new trend in the UK. Alprazolam has never previously been a big thing here, but some of these UK Xanax vendors are geared up specifically to sell in bulk to dealers. I don’t doubt this is a direct result of UK benzo users getting a taste of more potent benzos from the RC [research chemicals] scene. I also fully expect etizolam bars to come onto the UK market shortly, but I suspect these will be more popular given the street cred of Xanax.’

It is too soon to know if alprazolam will become a significant drug on the UK scene, but some of the key risks and issues are:

• Alprazolam may crop up unexpectedly in compounds where it was not the sought-after drug. It may also crop up in a variety of strengths, with pills containing alprazolam ranging from 0.5mg to 5mg (equivalent of 20mg – 100mg of diazepam.) On its own this is a significant risk of overdose. This risk goes up significantly when used in combination with alcohol or opiates.

• If alprazolam is appealing to a younger demographic, there is likely to be a high level of ignorance in relation to risks around benzodiazepine use.

• As with other benzodiazepines, alprazolam can cause significant physical dependency and dangerous withdrawal symptoms. Tapered reduction may be required, including high-dose prescribing as part of a transfer from illegally sourced drugs.

Alprazolam is certainly a significant drug – and a big problem – in America, and increasingly crops up in polydrug overdoses. From looking at its growing influence in this country, it would seem that the risks are very real.

Kevin Flemen runs the drugs education and training initiative, KFx. Visit www.kfx.org.uk for free resources.

More choice, more options

It hasn’t always been the case, but opioid substitution therapy is now accepted as a key instrument in enabling recovery. Having got this far – and despite the ever-present threat of cuts – is improving choice the next key step, asks DDN.

Although divisions inevitably still exist, and probably always will, we’ve come a long way since the sector was polarised by those bitter harm reduction versus abstinence arguments, with concerns over budget reductions and the austerity agenda perhaps helping to focus minds on the bigger picture.

A significant step on this journey was the NTA’s 2012 Medications in recovery report (DDN, August 2012, page 5), which has come to be seen as a landmark document. A fundamental re-examining of the treatment methods and objectives that can lead to recovery, it concluded that while ‘entering and staying in treatment’ and ‘coming off opioid substitution treatment’ (OST) were undoubtedly important indicators, they did not constitute recovery ‘in themselves’.

Delivered properly, OST had ‘an important and legitimate place within recovery’, providing as it did a platform of ‘stability and safety that protects people and creates the time and space for them to move forward,’ it stated.

What was also vital, it stressed, was to focus on broader support and make sure that OST is always delivered in line with clinical guidance.

Shortly after the report’s publication, Professor Oscar D’Agnone – at the time clinical director of CRI, and now medical director of London’s OAD Clinic –wrote a DDN article expressing hope that the report might help put an end to the false dichotomy between abstinence and prescribing and bring about a situation where services would simply choose what worked best from a range of interventions (DDN, September 2012, page 23).

Prof Oscar D’Agnone: ‘We’ve been witnessing massive reductions in treatment budgets… the recent rise in death rates is probably related.’

Nearly five years on, he feels it ‘was positive to move from a strategy based only on harm minimisation to a recovery-focused one that included harm minimisation,’ but that the creation of that ideal treatment landscape has been hampered by budget cuts. ‘Over the last couple of years we’ve been witnessing massive reductions in treatment budgets, which has had massive implications for treatment and implementing recovery strategies,’ he says. ‘I think the recent rise in death rates we’re seeing is probably related to these policies, and not just to aging populations.’ Those groups are simply the most vulnerable to these policies, he believes. ‘You have a lot of people over 55 or 60 who have been on prescriptions for years and they have been removed from those prescriptions for reasons that I don’t think are related to the recovery agenda, but to budget reasons.’

Indeed, the Medications in recovery report concluded that, while people should not be ‘parked indefinitely’ on substitute drugs – and that all prescriptions should be regularly reviewed – neither should arbitrary time limits be imposed. Is the sector more accepting of that position now? ‘Well, I think those statements are made from Mount Olympus, if you like – people on the ground are seeing different things,’ he states. ‘In my clinic, I have 48 people over 60 and eight people over 70. You can argue that these people should not be on high methadone or other prescriptions, whether that’s right or wrong, but what I’m saying is these people are alive and kicking and I’ll keep them on the same dosage. If I impose a reduction on them, they’ll start dying. And that’s what we’re seeing in the north west of England and other areas.’

It’s argued that time limiting OST not only threatens people’s ability to sustain their recovery but also risks increasing blood-borne virus transmissions, drug-related deaths and more. Would he go along with that? ‘Absolutely,’ he says. ‘It’s for the patient to say when the time has come to stop, not for me to impose that. The problem is that a heroin user nowadays is an old adult – they’ve been on heroin for a long time. Setting time limits for these patients is very, very risky. All these considerations about time limitations are based, basically, on budget reasons, not clinical reasons. There’s not a shred of evidence that time limiting will produce better outcomes.’

Ultimately, choice is vital when it comes to prescribing, he believes. ‘At my clinic I have patients coming from the public sector and the private sector, and we have a more open-minded view – they have more freedom to discuss the medications they’d like to take, and the doses. I’m receiving people who are on 1.5mg of buprenorphine, and all they wanted to be is on 2mg, but they’ve been told, “no, you have to be on 1.5, and reducing”. That’s ridiculous, and it’s putting people at risk.’

As part of the quest to respond to patient need, new versions of drugs are constantly being developed and trialled, including injections of naltrexone and buprenorphine that can last up to six months, as well as a rapidly dissolving buprenorphine wafer, now approved in the UK as Espranor. As standard buprenorphine capsules can take between five and ten minutes to dissolve – clearly far from ideal for supervised consumption in a busy pharmacy or prison setting – it’s hoped that products like this can help cut the drop-out rates for buprenorphine treatment, which currently stand at about 50 per cent within six months.

‘We’re finding administering Espranor takes about 30 seconds, so it’s certainly a much quicker product than the generic hard compressed tablet,’ says GP and substance misuse specialist Dr Bernadette Hard, who has been prescribing Espranor in her Cardiff-based service since January. While her service began using it in a criminal justice setting, they have since had some clients move their prescriptions to community pharmacies, she points out.

‘Our main motivation for wanting to trial this new preparation was the challenges we faced around diversion and misuse, and we had around 30 people when we did the initial switch,’ she says. ‘The people that we felt were appropriately on buprenorphine and benefitting from it had a very positive experience with switching – they liked the fact that it dissolved quicker and they didn’t feel they were being scrutinised, because if you are taking it properly but someone feels you might not be, that can be quite uncomfortable. Some pharmacists are really good and respectful, others less so.’

The feedback so far has been very positive, she says. ‘For those clients where we were always a little bit suspicious around their motivation for wanting to be on buprenorphine, some of them did struggle with the switch. Some found that – where they probably hadn’t been taking their full amount before – when we switched them onto Espranor they had to reduce their dose because they were finding it a little too strong. One or two have actually said they used to get bullied for their tablets, so they’d prefer to be on Espranor because they have fewer people requesting them, things like that.’

So how important is choice in substitute prescribing generally? ‘Well, we don’t have many options,’ she says. ‘You can try and categorise via a patient’s history who you think is going to do better on methadone or buprenorphine, and most of the time we’re right about that. But not always, and some people just gel with one product and I think it’s important that we respect that, in the same way we would in primary care. It’s part of building a mutual relationship, where you’re not just dictating to them.’

At the recent DDN service user conference, however, it was pointed out by user involvement activists that this is perhaps the only medical area where people don’t always have those conversations about choice with their doctors (DDN, March, page 8). It can often be a case of ‘here you go, I’m giving you this’.

‘I would challenge that, actually,’ she says. ‘There are areas where we can sound quite paternalistic and also where we’re being driven by budget, but that’s not exclusive to substance misuse. I think it can sometimes feel that way in substance misuse because an awful lot of the way we deliver services is by its very nature patern­alistic – because we’re supervising people and so on.

‘But I think more choice and more options is always going to be beneficial, and we have to get in there and use these things,’ she states. ‘I’ve been on development groups and the like, and we can all sit around as experts and ponder how this is going to pan out and where it’s going to be of most use, but sometimes you just need to use it – obviously in controlled way – to really understand where people are going to go with it.’

This article has been produced with support from Martindale Pharma, which has not influenced the content in any way.

Hub Manager – Oxfordshire

At Turning Point, we support people across the UK with substance misuse issues. In fact, we’ve developed our own fully integrated Drug and Alcohol service that provides its users with personal care and support that’s tailored to their individual needs.

Delivering this service from one single point of access, it’s all about doing things in a new way, and doing them more efficiently and effectively than ever before. Which is where our Hub Manager comes in.

Making a real difference to our users’ lives, you’ll manage our local Hub in Oxford – making sure its services are delivered efficiently, effectively and to the highest standards of quality. As well as leading and coordinating senior recovery workers, recovery workers, support workers and administrators, you’ll get to work closely with clinicians and line managers as you contribute to the planning of care and responding to ever-changing local needs. Which means it’s crucial for you to stay abreast of new developments in substance misuse and use your initiative to identify and explore new opportunities.

View this and over 50 other opportunities at: www.drinkanddrugsnews.com/jobs

Set target to cut Scots alcohol consumption by 10 per cent, say campaigners

The Scottish Government should establish a target to reduce overall alcohol consumption by 10 per cent over the next decade, says a new report from Alcohol Focus Scotland.

The government also needs to ‘address alcohol’s role in health inequalities’ and implement a 50p minimum unit price ‘as soon as legally possible’, urges Changing Scotland’s relationship with alcohol: recommendations for further action. The 10 per cent cut in drinking levels could potentially ‘deliver a 20 per cent reduction in deaths and hospital admissions’ after 20 years, the report states.

Scotland continues to have the highest level of alcohol consumption and alcohol-related harm in the UK, says document, which is published in association with BMA Scotland, SHAAP and Scottish Families Affected by Alcohol & Drugs. Despite the fact that 22 Scots die from alcohol-related causes each week – twice the rate of the 1980s – the Scottish Government has cut direct funding for alcohol and drug services by more than 20 per cent, the report states, leaving the NHS to ‘plug the gap’.

Alongside more investment in treatment and prevention, the document’s other recommendations include the prohibition of all price discounting, restriction of off-sales licensing hours, reducing children’s exposure to advertising and sponsorship, and improving the identification of children affected by parental drinking. The government needs to develop a strategic approach to reducing availability, it stresses, and provide clearer information about health risks to consumers. The recommendations come ahead of the Scottish Government’s ‘refresh’ of its 2009 alcohol strategy, Changing Scotland’s relationship with alcohol: a framework for action (DDN, 9 March 2009, page 4), which is due to be published in the summer.

‘Scotland is awash with alcohol,’ said Alcohol Focus Scotland chief executive Alison Douglas. ‘Widespread availability, low prices and heavy marketing are having a devastating effect, not only on drinkers but on their children and families too. Minimum unit pricing will hopefully be introduced next year, but further action is required to turn off the tap of alcohol harm, rather than simply treating the symptoms. This report provides a blueprint which, if implemented, will improve the lives of millions of Scots, make our communities better and safer places to live, and reduce demand on our over-burdened public services.’

‘As doctors we see first-hand the damage that alcohol misuse does to patients and their families,’ added chair of BMA Scotland, Dr Peter Bennie. ‘It is essential that as a society we redouble our efforts to tackle Scotland’s damaging relationship with alcohol. The proposals we are jointly publishing today will be the yardstick against which the Scottish Government’s willingness to go further will be measured, and show how we can build upon the work that has already been done to reduce the harms that are caused by alcohol misuse in Scotland.’

Meanwhile, the percentage of Scottish drug users seeking treatment for heroin has fallen from 64 per cent in 2006-07 to 47 per cent in 2015-16, according to the latest figures from the Scottish Drug Misuse Database, while the number of under-25s reporting recent heroin use fell from 58 per cent to 25 per cent over the same period. Although the percentage of people injecting has also fallen (from 28 to 18 per cent), drug-related death rates in Scotland remain worryingly high (DDN, September 2016, page 4).

Changing Scotland’s relationship with alcohol: recommendations for further action at www.alcohol-focus-scotland.org.uk

Scottish drug misuse database: annual report, 2015/16 at www.isdscotland.org

Springboard to success

RAPt’s apprenticeship programme is helping people to use their experience of addiction to get back into work, as Nathan Motherwell explains.

Since 2013 RAPt have been running an apprenticeship programme with a difference, and it’s been quite successful. We recruit apprentices to work in our drug and alcohol treatment services across the country, helping people to address their addiction – and our apprentices are all in recovery themselves. So while helping people into work, the scheme also supports people in their own recovery.

The apprenticeship scheme is about recognising the value of people’s personal experience of addiction and recovery, so we don’t have any maximum age restriction. In fact, I’m quite proud to say, the average age of a RAPt apprentice is 45. RAPt managers report that apprentices provide a visible example of recovery in action, bring new energy to the teams, and offer extensive personal experience of addiction and recovery. Feedback from other RAPt staff has been that apprentices bring fresh motivation, as well as a unique energy and passion that can change the whole team dynamic in a very positive way.

Many of our apprentices have little or no work experience, and no previous experience is required. Some have been in recovery a while and are looking for a career change after working in another field, while others have voluntary experience and are looking to get their first paid job.

The apprentices work towards a level 3 NVQ qualification in substance misuse or counselling. The scheme ensures that we offer significant support and learning every step of the way – all apprentices are allocated a mentor as well as a line manager. They get a wage of just under £20,000 a year for the London areas, and we also pay an allowance for external supervision and provide regular support meetings.

A lot of our apprenticeships are based within prisons in London, Kent, Norfolk, Surrey and Sussex. One of the challenges has been getting people with criminal convictions the security clearance to work in the prison system. We have also offered a large number of apprenticeships within our community projects and administration roles at our head office.

The results of the scheme are amazing, especially considering the challenging nature of working inside prisons. In the last three years we have offered more than 80 recovering addicts and alcoholics apprenticeship placements at RAPt. We only have a 15 per cent dropout rate from the scheme and 80 per cent of all apprentices who started with us completed their apprenticeships and went on to secure further employment. Many of them have moved on and are now working for other service providers, as well as many being employed permanently with us at RAPt.

With the new government apprenticeship levy coming into force this month, funding could become available for apprentices of all ages. We are hoping this could enable RAPt to expand the scheme and roll out our apprentice programme to other service providers. Nathan Motherwell is RAPt apprenticeship co-ordinator and a former RAPt client in recovery


‘Their faith in me was priceless’

Former RAPt apprentice Gary Broadway shares how the scheme started his career.

I had my last drink in 1995 and I’ve been sober ever since. When I found out about the RAPt apprentice scheme, it seemed like the ideal next step for me.

My role as a drug and alcohol practitioner apprentice involved a huge variety of things, from admin to working with clients. I went to college as part of the scheme, gaining NVQ levels 2 and 3 in counselling. RAPt were great and made sure that I got the help I needed.

My favourite thing was working with challenging clients and seeing the difference in them, as well as learning new skills. I’d never used a computer before I started, but soon learnt to use one to write reports. My confidence grew so much, as well as my skills. When a job as an alcohol worker came up, I decided to go for it and I got it.

To be given a chance to be an apprentice is an honour and I’m eternally grateful. RAPt had faith in me and that feeling is priceless. It’s wonderful to be able to tell my kids about what I’m doing – they’re so proud of me. I would tell anyone to have a go at the apprenticeship. It has been an amazing chance and has shown me I can now have a career in a job I love.