In early 2020 the global pandemic had a significant effect on the wider NHS but also community drug and alcohol treatment services, forcing services to rapidly change how they delivered care as well as prescribing practice (see table below). In community drug and alcohol treatment services the need to protect the public and staff by minimising contact during lockdowns meant the unprecedented rapid risk review of every person on opioid substitution treatment (OST), as well as reducing pharmacy collection frequency or supervision for the majority.
The outcome of this rapid change in prescribing practice, and the inability for prescribers to have OST supervision as a safety net, was increased anxiety – namely the very real concern that many people might overdose and the expectation of a large number of opioid-related deaths.
PRESCRIBING PRACTICE
Prescribers rely on the Drug misuse and dependence: UK guidelines on clinical management (‘orange guidelines’) for reassurance that their prescribing practice follows a consensus of safety and an evidence base. A part of this guidance relates to OST collection frequency and supervision by a pharmacist, which during the earlier period of the COVID-19 pandemic was required to be adapted by prescribers across the country.
Following the pandemic, Inclusion (part of Midlands Partnership University NHS Foundation Trust) conducted an evaluation study – Giving up the guidelines: a qualitative evaluation of disrupted prescribing of opioid substitution therapy in a rural UK county during and following the COVID-19 pandemic – to explore the period of time from the first national lockdown to post-pandemic. The study had one question in mind – what was it like being a prescriber in community drug and alcohol services during the pandemic?
Among the findings of this study was that prescribers were initially fearful of the impact of the prescribing changes but some later perceived benefits. All had concerns about the potential for increased overdoses or deaths, and many had fears around the legality of their own prescribing practice. While national data from methadone related deaths is available and continues to be analysed, the service studied did not see a significant increase in deaths itself during this time.
However, supervised consumption may mean there is less illicit methadone available to people not engaged with services, and therefore can have a protective effect on the wider community. Prescribers also had mixed views regarding how greater flexibility in OST collection had given people better ownership of their medication, with some noticing a reduction in the use of heroin. Prescribers in the study also noticed a shift in power dynamics, and some reported later feeling a greater sense of flexibility with the orange guidelines.
POWER DYNAMICS
The issue of power dynamics observed within the study is particularly thought provoking. Some prescribers observed a change in people feeling more empowered to self-manage their OST where they may not have done so previously. This – alongside seeing how hard staff within the services worked to deliver OST to home addresses as well as conducting welfare calls – was perceived by prescribers to have enabled people to feel a greater sense of care from professionals.
When the relaxation of the new prescribing practices came into effect, prescribers in the study experienced challenges when encouraging people to come back into the service for appointments. They also encountered some resistance when increasing the frequency of collection of OST or returning to daily supervised consumption.
Following the pandemic, some changes made to practice during the lockdowns – such as telemedicine – have been kept in some form. The services have also altered the way assessments and reviews are delivered, having learnt there are other methods to deliver care in some circumstances. However, many prescribers described the need to complete some medical assessments face-to-face to effectively assess physical health needs.
POSITIVE CHANGE
There were positive examples of changes to practice resulting in benefits, such as the use of online psychosocial therapy groups. One prescriber noted this was more accessible for people with anxiety, and some saw increased interest in accessing groups this way during the pandemic. In our organisation post-pandemic we have now seen a slight decrease in the number of people placed on daily supervised OST. With the participants in the study raising issues around empowerment and conflict, however, we are left with a question around how power dynamics might play a role in community drug and alcohol treatment services.
As practitioners, prescribers or service providers we may need to explore the concept of power dynamics in further detail, perhaps with supervised consumption as a starting point. Supervised consumption was implemented for a reason, and it continues to have a significant role in reducing deaths – both in terms of its intended recipients and in reducing the risk of diversion. There is a very real complexity in balancing the risks between opioid overdose, diversion of methadone and methadone-related overdoses while involving people accessing drug treatment services in the decision-making process around their treatment.
However, the pandemic and changes to practice may suggest we need to better understand how we achieve the equilibrium between managing risks and being unnecessarily restrictive. Further exploration of how we personally interpret policies and guidance alongside our own personal preferences and biases, may be needed. Additionally, we may need to give thought to how the concept of power dynamics is reflected upon, both in practice and during training.
TOUGH QUESTIONS
If we are working in drug and alcohol treatment services we automatically have a position of power which we must be aware of, and we need to be conscious of how this may affect the people we serve. We might also need to ask ourselves the tough question of whether power dynamics plays a role in people not accessing community drug and alcohol treatment services, and, vitally, how we better balance the management of risks with enabling the empowerment crucial in a person’s recovery – however they define recovery for themselves.
If we need to review how power dynamics play out in other parts of the care we deliver, perhaps we also need to consider the complex landscape of stigma, and how it affects people in other parts of the healthcare system.
Do we have it in us to take a new look at how we operate in the context of power dynamics?
Deanne Burch is programme lead for Hep C U Later and Dr Georges Petitjean is clinical director and medical lead at Inclusion, part of Midlands Partnership University NHS Foundation Trust