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.