Tuesday, 25 June 2013

The Future

University 

So I'm applying to do a music degree at goldsmiths next year. 
It's a BMus, they do music or popular music. For the music course they want more things like GCSE's and a grade eight on your main instrument. Well, I didn't hang around at school long enough to get GCSE's, I sat my music one incidentally and got an A. Technically I hold up to grade six on piano but again I dropped out at about seventeen. So the popular music course is a little easier to get on, no qualifications necessary, just a talent and passion for music. I had a quick chat with one of the tutors and, reading between the lines, I have a pretty good chance of getting on the course. She told me they have to get 400 plus applicants down to 200 for interviews, they then get that down to just 50! Funnily enough I never even knew that university picks you, not the other way around! Haha. So she told me that a lot will come down to the personal statement, she recommended I start playing more live and to get some tracks recorded. I have just over a year to prepare anyway, pretty excited about it!
I might, in the interim year, go back to college and complete the final year of my counselling and psychotherapy diploma. I'd technically be able to practise as a counsellor then, which is a scary proposition! Haha
It would though go towards my final goal of being a music therapist, after three years getting a music degree I'd then go on to do some kind of therapist/counselling course. I think goldsmiths actually had a specific music therapy course. They have a pretty decent social sciences department anyway. 

Music is really the only thing I get passionate about, it was my solace after I was abused aged eleven. We had a baby grand in the house we were renting at the time, which sounds terribly posh but believe me it weren't. I'd spend hours and hours lost in my own world. Literally working out how to play a triad chord, I learnt how to play by ear, listening to a song I liked on a loop, pressing keys until I found which ones sounded right. Stabbing out the melody and pressing base notes to match. I taught myself 'Eternal Flame' like this, 'Let it be' and 'Imagine'. It was around the time meatloaf had 'I would do anything for love' out and I remember playing it full blast and hammering it out on the piano, imagining I was on stage playing it live.. Mum noticed I was good and somehow found the money to pay a little old lady down the road to give me lessons. I had to suddenly learn these really basic classical pieces and read sheet music. I thought this was boring and would go home and play some twelve bar blues! To this day I hate playing from a lead sheet, once I know the chord progression for the song ill play it how I want to. 
I took cello and trombone lessons at school, randomly.. Initially I wanted to play the bassoon but only because it looked like the coolest instrument in the orchestra! I taught myself guitar and by 14 I was busking Bob Dylan songs on the streets of Brighton with a harmonica around my neck. Not to sound like I'm bragging but I can pretty much pick up an instrument and work out how to play it in a few hours, ok, maybe we can strike the saxophone and oboe off that list! I taught myself piano accordion a few years ago. It was a 120 key piano accordion that I found in a skip! Seriously I have no clue how they play those things! I'm pretty musical anyway, I'd love to work with music somehow so therapy sounds great!

I should have a degree by the time I'm 36 and be fully qualified by 40! Haha.. I probably should have done it a few years ago but hey, never too late :) 

Getting funded to do all this is a whole other issue though, I have no idea if I can get a student loan for this, especially the full three years. 
It's £9,000 per year just for the tuition. I'd have to look into grants for living and housing costs. I guess they do those?
I read that you don't start to pay the tuition fees back until you're earning £26,000 annually. And then it works out about £5 per week which isn't too bad I think. 
At least it's possible to get the damn things. In other countries you pay for your learning, most American families start saving for college from youngsters. 

I can see why students are pissed off about fees increasing, by the time these kids graduate they're often £30k or more in debt!
It's a pretty hefty wedge of money to be stuck with before you even start to earn. Maybe I'm lucky being a mature student, the tutor I spoke with was saying it goes in my favour, my age, life experience etc make me a good candidate, I guess they like to mix it up a bit when it comes to new students. It would be pretty boring having just school leavers. 

I'm really looking forward to it all anyway, I just have to pull my finger out before September and get some stuff recorded. I can do that easy :) 

I did record my version of 'Bohemian Rhapsody' a while back. It's on YouTube 

Monday, 24 June 2013

Complaining To Your Drugs Service & Injectable Script Progress




East London NHS's Stance On Injectable Opiate Prescribing

So, this post is about my experiences dealing with the SAU, or, 'Specialist Addiction Unit' at our local hospital, Homerton (Hackney East London), a run down of the various letters sent back and forth on behalf of my friend and the unit's addiction consultant psychiatrist,manager and the clinical director...

The issues I raised and the hospitals responses are quite generic and I would have thought other drug services around the UK operate similarly, if you were looking into other treatment options for yourself. 
I guess I've been acting as an advocate on her behalf, having someone fighting your corner, who also incidentally knows and understands how it all works, can work wonders for your self esteem and seems to have a positive effect on how well the professionals involved with your care behave ;)

This post may well piss people off, I know that a large percent of the general public probably view drug users and heroin addicts especially, as a problem for society, I'd go as far as to say sub-human, undeserving of love, compassion and tax payer money.
Sadly, the average citizen views heroin addicts as scumbags that would sell their own mother for a hit.
This isn't helped by the media, on the whole, if a news story concerns a heroin addict it will revolve around a mugging of an old lady for the £5 in her purse. The stereotypical dirty junkie.
This is also, probably the only time the public are told about heroin addicts, most don't know one or have any kind of contact with one. The message is clear, beware the scummy junkie, he'll mug you and won't think twice about it as he has no conscience or care for you.
Now, the reality...
There are an estimated 300,000 heroin addicts in the UK, that's just the ones that are registered for treatment and in receipt of maintenance scripts.
300,000 is a conservative estimate, for every addict in treatment there is a mother with kids too scared to access treatment for fear of social services getting involved, for every one in treatment there is one working in an office, holding down a good job, terrified of going to his/her GP for fear of being judged or losing their job. For every one in treatment there is another that can afford private healthcare, being prescribed MST from a private doctor or clinic..
My point is there is a huge amount of opiate addicts that slip under the radar, working, paying taxes, getting on with it! The 'functioning addict' I guess I'm one of them, I've always worked and supported myself and my drug use, I've always believed if one wants to use drugs then one must also support oneself and not expect others to pay for or support my habit.
Maybe people like me are in the minority, I don't know, I get the feeling there are lots of us though.
Now of course there are also your 'car crash, live to die' junkies.
These are the ones that commit crimes to pay for their drugs, most are in treatment, on scripts which for all it's negatives, gives you the option to use, being on methadone takes away the requirement to find money every day.
Sure, there are plenty that will steal, rob, lie, blag, do whatever it takes to get high.
In a society that criminalizes drug users and doesn't provide adequate prescribing of inject-able opiates, there are, unfortunately, those that will commit awful crimes.
I don't believe, in my heart, that the ones that mug old ladies actually want to do so, no-one gets off on stuff like that, it comes from a desperate place. I know they will have that on their conscience forever and so they should, I'm not condoning it in the slightest, I think it's disgusting, but I think simply punishing the person without any kind of constructive treatment is unhelpful and pointless.
It pisses me off that all addicts get bunched in with those that go that low.
Iv'e never in my life mugged anyone, Iv'e never stolen from my family, if anything I kept well away from my family when I was at my worst. I'm not trying to make out I'm mr goody two shoes but I am saying that despite the drug addiction, we still have a conscience, we are still human beings, we are your brother, sister, mother, father...
At my worst I spent a couple of years living on the streets in Brighton, I slept in car parks with a few other addicts. We would get up early and go begging or sell the big issue, I used to have to keep everything I owned in my sleeping bag, I'd make sure I had a hit made up ready from the night before for the morning.
Waking up sick in the freezing cold it's the only thing that keeps you going.
They were bad times but still I never mugged anyone, I begged for change and shoplifted occasionally. Only ever food though, I wasn't very good at shoplifting bigger goods and frankly couldn't be bothered.

So, my point is this.. Drug addicts are people too, people that have lost their way for whatever reason, usually some kind of abuse as kids. We're fellow human beings with feelings and dreams, don't judge us too harshly or quickly, this world needs more compassion and love not judgment and hatred.

So, onto the letter.. :P

So, a little background, if I maybe haven't covered it in previous posts...

She is a little younger than me, 30, with a long history of IV drug use, ten years plus. 
More recently (the last few years) she's been injecting 'speedballs' so crack cocaine along with the heroin. 
She has limited peripheral venous access having used the veins in her arms and legs for many years meaning the usual areas like arms and legs are thrombosed and the veins collapsed. 
She is therefore a femoral/groin injector. She's been injecting in her groin for about three years too. 

She has been in and out of treatment for around 15 years, various attempts at rehab (9-10 times?) methadone and subutex maintenance (small and large/optimised doses, the maximum being 130mg), DIY/home detox, 'community' detox (Home detox under the advice/support/comfort medications of GP), dihydrocodiene, morphine... Etc

In total in the entire length of using illicit drugs, the longest she ever managed to stay 'clean' was about a year, in 2004. 
She is currently prescribed 60mg oral methadone, on daily supervised pick up.
She still uses heroin and crack cocaine on top 3-4 times a week, an average 'hit' for her is three bags of heroin and one crack-or about 0.6 grams heroin plus 0.2 grams crack. She will usually inject this amount three or four times in a day, costing around £30 per shot. She struggles daily with drug cravings and withdrawal symptoms. She doesn't feel her current treatment of 60mg methadone 'works' or is even keeping her out of physical withdrawal. 
Traditional treatment has had little effect in the long term and she wants to try something new. 

Ok, so in my opinion my mate is a perfect damn candidate for IV opiates, ideally heroin (diamorphine), although IV methadone would also be an option. She feels that her addiction is as much to do with the physical act of injecting as it is to anything else. 
In her words she has, and always has had, a 'needle fetish' in other words, using IV drugs is almost a ritual, similar to rolling a joint or mixing a drink I guess. Some users become almost obsessive about how and where they prepare/cook and use. The act of tying off, finding a vein, pulling back and shooting becomes so ingrained, if you think about it from a CBT point of view, the reward is the hit. It's usually preceded by hours of hustling, shoplifting, sex work, whatever... Obtaining cash then obtaining the actual drug/s is all part of the addiction. This reward system is particularly strong when the user is in withdrawal, or has had to work extra hard to get the cash.... I can totally relate to and empathise with her, I was very similar..
I know for me at least, I was hooked on the whole process, running round scoring and finding a quiet corner or public toilet to shoot up in was all part of the attraction for me, maybe it's the knowing what you're doing is illegal/bad for you/dodgy.. Whatever, I got off on shooting a speedball in a public loo as much as the hit itself... Yeah.. Go figure mr psychologist ;)

Anyway.. As no other treatment has ever really worked, and she continues to inject illicit drugs on a near daily basis, with all the associated risks, I see injectables as a good option, it would be a method of harm reduction, she believes she can exchange her speedballs for a single, clean methadone or diamorphine shot. Cutting out the crack altogether. Pharmaceutical grade opiates are obviously also much less damaging to inject than adulterated street drugs.

After reviewing the NICE (National Institute Of Clinical Excellence) and NTA (National Treatment Agency) guidelines, she fits all the eligibility criteria so technically there is no reason she should be refused. 

I put all this, in writing, to her consultant, the unit manager and the clinical director ..Who, by the way, holds the requisite home office diamorphine/dipipanone license. 

Recently my friend has had a string of seemingly ever changing and frankly, bloody useless 'key-workers', I've been telling her to ask to see an actual doctor for months but apparently it's near impossible up there,.. at the 'SPECIALIST addiction unit' (Yeah, I'm annoyed, it was no better when I was there). They seem to specialise in doing as little work as possible, you might get asked to do the health assessment, otherwise it's just a case of handing out a blue script every two weeks and off you go. 

We talked about the lack of specialty care at the unit, along with the high staff turnover and the de facto issue of confidentiality and continuity of care. We asked for an actual doctor to assess her for possible injectable prescribing and told them that we felt the unit was no longer even providing a basic duty of care to its clients any more. (Managerial talk for 'oh dear, duty of care is rather important')

Strangely enough, this seemed to get quite the reaction!
She was telephoned days later and informed that as her complaint was rather serious it was being referred directly to the trusts' complaint department. 

She was asked to attend an appointment with a consultant from the neighbouring boroughs drug service to clarify the points she had raised. 
She duly went along, as did I. 

I have to say, we were pretty impressed with how the complaint was dealt with, the doctor asked her exactly what she was unhappy about and we discussed the possibility of injectables. 
He told us that he'd be carrying out a thorough investigation of our SAU and the staff involved, and that he'd look into the injectables issue. 

Fast forward two weeks...

She's called back again to see this consultant. 
He agreed with her issue around not being able to see a doctor when requested and said he'd be hopefully putting a system in place with a time limit when a request is made.. He assuaged her other minor issues and moved into the IV script..

Long story short..

Yes, she fits most of the eligibility criteria, 
yes on paper she would probably benefit from this intervention,
yes he agrees that studies from IV prescribing show very positive results, 
yes yes yes pretty much..!

Oh, wait though.. We can't do it because we don't have the facilities/staff/money/home office licence/lives in the wrong part of London/worries she will inject in her neck/groin which rules out treatment..

Blah blah..

My take on it?

He thinks it's a good idea but his hands are tied with beaurocratic   nonsense red tape and government guidelines. 
Apparently, starting someone on any IV script (methadone or diamorphine) is a big deal. Most people with IV scripts are long term, inherited patients. Initiating new scripts is rare as hens teeth. These 'grandfathered in' patients are pretty much regarded as long termers that the doctors would rather not have to deal with. 
The NTA guidelines state that the client must be observed for an initial period of time when initiating IV treatment, demonstrating safe and correct injection technique. (Not in the groin or neck, which is a whole other issue and personal gripe of mine, by the time a service user may be suitable for IV prescribing they usually have very limited venuous access anymore). 
To do this means the unit needs a specialist nurse and a room. 
See, to me that ain't really a big deal, but apparently it is. 
The client would need to attend the unit and be observed twice daily for at least three months. They would get one take home a week for the Sunday and would need to return the empty ampoule, proving they weren't diverting their script (Again, really? why on earth would they 'divert' the drug they want and have fought tooth and nail for?!) 
The prescribing doctor would require a home office licence, they would also want to be experienced and comfortable providing the script. (Funnily enough, there are barely any with the experience and confidence to do this) 
Apparently it's quite a big thing to take on and the vast majority of doctors would simply rather not get involved. 

I think, that really, it's just the fact that the government have made it so bloody difficult to provide this kind of treatment that no doctor wants to do it!

There was an outside chance of a referral to the maudsley hospital in south London. This is where the drug unit that did the RIOTT trials is based.  
IF, and I mean IF, she managed to get a referral and was accepted, she would be under the same rigorous and thorough regime. 
Having to travel halfway across London twice a day to inject in front of a nurse..and seriously..you'd need to be pretty bloody desperate to do that!

Currently we're waiting for the investigating consultants report. 
It should be completed any day now, I'll update you all as we know more. 

What came out of this all is the following;

-It is technically possible to get an IV opiate script
-There are only around 300 doctors in the UK with the necessary licence, these are not evenly distributed throughout the country. 
-You're very unlikely to get injectables prescribed, particularly if you live outside the main cities
(Brighton and London both have provisions although they're near impossible to access)
-Be prepared to face a lot of hostility and red tape, whether its right or wrong, a lot will come down to the individual doctors personal beliefs/ethics/experience/preferences/prejudices etc
-Even if you manage to find a doctor willing to work with you, there's no guarantee the PCT will fund it, in comparison to traditional oral alternatives, ampoules are very expensive 
-Our current Tory governments drug strategy is to go against all the evidence and previous experience and focus on abstinence based treatment. Ie: getting you off your methadone script as fast as possible (Yes, I'll be posting about this issue soon)
-Get some advocacy, it can really make a difference! Look up the methadone alliance, RELEASE and local users groups
-Do your homework, presenting a well researched, sensible and concise case will make a big difference


As I was saying before, the reputation and stigma attached to heroin/crack cocaine addicts is one I have to battle with on a near daily basis. Sadly this prejudice can often carry through to the very people that are meant to help us, doctors, nurses, drugs workers even. 

Don't just lay back and accept the status quo, being ambivalent and passive with regards to the treatment you receive is what's expected of you. 
Drug treatment strategies in the UK rarely change and are nearly always led by politicians that certainly don't have your best interests at heart. Drug treatment is a controversial area and MP's make decisions based on public opinion. Not on evidence based and patient centred choices. 

Advocate for yourself and others, join your local drug users group, if there isn't one, start one!

As I've said many times before, addiction is not a 'one size fits all' problem. 
There are many factors that contribute to a person becoming addicted to drugs and alcohol.
Addiction crosses all social boundaries and classes. 

Ill leave you with this;

The consultant we saw told us he was very impressed we had written a letter of complaint. He told us it was a real novelty, to meet someone who wanted to bring attention to issues with their treatment. 
He told us that most complaints come in the form of kicking off and shouting in the waiting room, the client storming off when he'd got what he wanted. End of story..
To get some real feedback and the chance to make the patient experience better was something he was more than happy to do! 

So... Get writing :)

Love

Sid 

Saturday, 8 June 2013

Nearly Six Months, PAWS And Stopping Smoking!




I've not been too good at writing posts recently, my only excuse is that when I cleaned up, life kinda took over!

It's coming up on six months now since my last Iboga flood. 
Apart from a couple of minor slips, ie: one or two small shots, months ago, I haven't slipped back into a full time opiate habit, nor am I on any maintenance meds anymore! :)

As ever when coming off long term opiates, it takes quite some time for the body to heal and adjust. Often longer than you expect, actually when I got clean back in '06, I tapered myself off a 120mg a day methadone habit. 
It took about 18 months of dropping 1-2mg each 4-5 days. 
It was slow and arduous but it worked, I got three years opiate free after that too!
I'd never heard of Ibogaine at that stage, if I ever had to do a slow meth taper again I'd microdose with rootbark without a doubt. 

Funny too, I'd not heard of the dreaded PAWS back then either, I think if I had I'd have probably talked myself out of the detox, or at a minimum suffered a lot more. 

Looking back now, knowing more, I did struggle with it. From 120mg down to about 12mg was easy in comparison to that last 12mg!

I got so worked up convincing myself that the last drop, from 1mg to 0 I'd go into hellish cold turkey that I nearly talked myself out of it altogether! I started to do the addict thing of coming up with justifications why I should just stay on 12mg forever! Haha

As it happened, I actually swapped over onto subutex for the final bit. It wasn't easy, the transition is difficult and I got pretty sick. I was really pissed that I ended up needing a full 32mg to hold me, I thought I'd be ok at 16mg max! 
It took about a week of pretty shitty withdrawal symptoms to stabilise, I then stayed at the 32 for a couple of weeks then started tapering. 
It was much easier to taper with, I set myself a three month limit for taking subs, much longer and I've noticed people start to struggle getting off. 
I got right down to 0.02mg, shaving the pills with a razor. 
When I finally stopped altogether, I remember sitting at home that day waiting for the ct to hit me, I had subs on hand if it did... It never did!

Yeah, I was amazed.. But it just goes to show, if you have the discipline and willpower to taper it is possible..

Anyway. I'm getting off track..

I wanted to talk about PAWS, or Post Acute Withdrawal Symptoms/Syndrome, like I said, I'd never even heard of it, so I didn't really know what to expect in the way of symptoms when I finally stopped. 

Physically I had minor sweats and chills, goosebumps and sneezes that went on for maybe another week or two, my main problems were insomnia and depression. 
For about a year after I stopped I was battling severe depression, I researched medications and antidepressants that were good post opiate addiction and the SNRI Venlaflaxine/Effexor came up. I asked my doctor and was prescribed Effexor. I can't say I felt on top of the world but if lifted me out of the suicidal zone. 

It seems to take about a year to fully recover from long term opiate abuse, after that time I felt pretty much 'normal' and happy and had forgotten all about my past life really. 

Why am I talking about this? 

I guess because its kind of where I'm at again now, feeling sad and suffering a lot of anxiety. 
Iboga rootbark helps me loads, I take about a gram whenever I feel I need it, which is usually about every two weeks. It seems to stop any drug cravings I'm having dead in their tracks and lifts my mood. 

I actually even stopped smoking about six weeks ago too. Which is just crazy for me, I've always loved smoking and never had much intention to stop. 

I bought one of those E-cigs from the pharmacy and never looked back, haven't smoked since! :)

Can't recommend them enough

That's all for now anyhow 

Sid 

Friday, 24 May 2013

Richard Branson Calls On The UK Government To Repeal The 1971 Drugs Act






Yes, I'm surprised as you probably are! 

Richard Branson, of Virgin Ltd, has recently posted a blog that urges the government to look again at our failing 'war on drugs' and urging that we look at other ways to deal with drug addiction, addicts, associated crime and social problems.

He includes a link to this petition, started by an MP from the Green Party in Brighton, which urges an immediate enquiry and investigation.

This is from the petition page:

Drug related harms and the costs to society remain high in Britain, with a growing consensus that the current enforcement led approach is not working. In recent months the independent UK Drugs Policy Commission has highlighted the fact that Government is spending around £3 billion a year on a policy that is often self-defeating; and the Home Affairs Select Committee has concluded Government action is needed "now, more than ever" to consider all the alternatives to our failing drug laws and learn from countries that have adopted a more evidence based approach. We are concerned that, in this age of austerity, nobody is checking whether Britain's current approach is value for money - or money wasted. We therefore call on the Government to commission an authoritative and independent cost-benefit analysis and impact assessment of the Misuse of Drugs Act 1971 within the next 12 months, in order to provide the evidence for Parliament to pursue a more effective drugs policy in the future.

This is positive news and I suggest you all sign and share it!

It seems the issue of our outdated and unfit for purpose drug policies here in the UK seem to be being talked about more often in the news recently. I hope and pray this is the start of the tide turning here.

As Portugal and holland have proven, the decriminalisation of drugs and the treating of addicts as people that need help, as opposed to criminals and lost causes, works!





Thursday, 4 April 2013

UK Government Injectable Opiates Prescribing Guidelines






Link here to the NTA (national treatment agency) UK injectable opiate prescribing guidelines

I've quoted below the most important parts... There is a lot of interesting information in the PDF so I would suggest reading through if you have an interest in the subject

This is taken from the PDF. The main message from the NTA is that the following eight principles should be adhered to when considering prescribing injectable opiates:

This link is the guidelines issued to my local NHS specialist addiction unit, it's specific to east London but the guidelines are probably applicable to most drug services nationwide.

        Principles guiding injectable maintenance prescribing

This guidance recommends that injectable maintenance prescribing should only be undertaken in line
with eight principles.

1. Drug treatment comprises a range of treatment modalities which should be woven together to
form integrated packages of care for individual patients.

2. Substitute prescribing alone does not constitute drug treatment. Substitute prescribing requires
assessment and planned care, usually with other interventions such as psycho-social
interventions. It should be seen as one element or pathway within wider packages of planned
and integrated drug treatment.

3. Within the substitute prescribing modality, a range of prescribing options are required for
heroin misusers requiring opioid maintenance. Some options may carry more inherent risks
than others (e.g. injectable versus oral options). Patients who do not respond to oral
maintenance drug treatment should be offered other options in a series of steps. This would
normally include:
• oral methadone and buprenorphine maintenance, specifically optimised higher dose
oral methadone or buprenorphine maintenance treatment, then
• injectable methadone or injectable heroin maintenance treatment (perhaps in
combination with oral preparations).

4. Injectable maintenance options should be offered in a local area that can offer optimised oral
methadone maintenance treatment including adequate doses, supervised consumption and
psycho-social interventions. This is essential to ensure oral drug treatment options have been
fully explored prior to a trial of injectable maintenance treatment and to ensure smooth
transition back to oral treatment if required.

5. Injectable and oral substitute prescribing must be supported by locally commissioned and
provided mechanisms for supervised consumption. Injectable drugs may present more risk
of overdose than oral preparations and have a greater value on illicit markets and hence may
require greater levels of supervision.

6. Injectable maintenance treatment is likely to be long-term treatment with long-term resource
implications. Clinicians should consider the move from oral to a trial of injectable preparations
carefully, including long-term implications for the patient and drug treatment systems and
involvement of services.

7. Specialist levels of clinical competence are required to prescribe injectable substitute drugs.
Heroin prescribing also requires a Home Office licence.
8. The skills of the clinician should be matched with good local systems of clinical governance,
supervised consumption and access to a range of other drug treatment modalities.



         Clinical eligibility

The expert group reached some consensus on eligibility criteria, precautions and outcome measures.
However, guidance on issues such as dose or the prescribing of combinations of oral and injectable
preparations will require further work.
The agreed criteria are set out in full and relate to factors such as:
• age and drug usage
• willingness to comply with conditions such as supervision and monitoring, engagement
in a range of care options, avoidance of some risky behaviours and of diverting prescriptions
into illicit markets
• persistence of poor outcomes within an optimised oral programme.


         Recommendations

The key recommendations are that:
• optimised oral methadone maintenance should be the maintenance treatment for
the majority of heroin users
• injectable heroin and methadone treatments should be considered only for the minority of
patients who are genuinely unresponsive to an optimised oral maintenance treatment approach
• injectable heroin and injectable methadone treatments based on this guidance should
be seen as a new drug treatment modality requiring the development of new integrated
care pathways.



         Key messages

The document has four key messages:
1. The prescribing of injectable substitute opioid drugs may be beneficial for a minority of heroin
misusers. The document makes preliminary recommendations on eligibility criteria.
2. Future maintenance prescribing of injectable heroin or methadone should only be undertaken
if it is in line with eight principles identified by the expert groups. This is essentially a new
standard of injectable drug treatment to that previously provided in England. Applying these
principles in practice, sets a high standard for delivery of this treatment intervention, in
recognition of the risks involved.
3. Services should be improving for patients already in receipt of injectable maintenance
prescriptions for heroin or methadone. Where patients are stable, maintaining this stability
is paramount.
4. Priority should be given to improving the effectiveness of oral maintenance treatment (on
methadone or buprenorphine) for the majority of patients in all drug action team areas in England.



         Clinical evidence

The following statements were agreed as consensus on ‘clinical evidence’ by the expert group based
upon many years’ experience of prescribing heroin and other injectable drugs.
Statements from the expert advisory group

1. We consider that the prescribing of injectable substitute opioid drugs, including heroin and
methadone ampoules, may be of benefit for a minority of heroin misusers. In principle this
should be part of a range of potentially available drug treatment options, provided it is set
in the context of a comprehensive drug treatment package.


2. We consider the prescribing of heroin and other injectable opiate maintenance treatment is
not a first-line treatment for dependent heroin users. Injectable opioid maintenance treatment
(including injectable heroin maintenance) is an exceptional treatment that should only be
considered for patients who have not responded to optimised conventional oral
maintenance treatment.


3. We consider that there may be greater inherent risks with injectable opioid treatment, when
compared with the better-studied oral methadone maintenance (and other treatments, such
as sublingual buprenorphine maintenance that has less risk of overdose). These include
greater risks of overdose, continued injecting harms and greater risks of diversion and abuse
of medication. Formal consideration of the risks and benefits of injectable opioid treatment
should be undertaken with all potential patients, particularly those who may be at highest risk.


4. We consider that these risks and dangers (to the individual patient and to society at large)
can be greatly reduced by adherence to practices and procedures which increase
compliance with treatment, and which reduce prescribing to inappropriate patients, erratic
use and diversion to the illicit market.


5. We consider the assessment of potentially suitable patients, and the subsequent initiation of
injectable opioid maintenance treatment, to be a task that requires considerable experience
and expertise in the addictions field, and which should consequently be undertaken by a
competent specialist doctor* working in an appropriately supported treatment setting.


6. We consider that the wider safe provision of injectable opioid maintenance treatment
requires substantial identifiable resources and facilities (as recently established in Switzerland
and the Netherlands). These are required in order to make possible the wider provision of
injectable maintenance treatment options and thereby achieve these greater potential benefits
to the patient and society whilst minimising adverse consequences.



           Cost and cost-effectiveness of injectable substitute prescribing

Injectable substitute drug treatment is a relatively expensive drug treatment option. Calculating cost
and cost-effectiveness of different types of drug treatment is complex and attempts to do so are
compounded by a lack of agreement on appropriate methodology. The NTA is engaged in further
work to provide more accurate and consistent unit costings of drug treatment modalities and options.
Strang et al (2003) estimated that injectable methadone represented 20 per cent of the methadone
prescription drug costs in 2001 for four per cent of treatments. Indeed injectable methadone and heroin
treatment has been estimated to cost between 5 to 15 times as much as oral methadone treatment,
depending on the content of treatment packages and arrangements to supervise consumption.
Surveys of clinicians indicate that the cost of injectable heroin in particular is a prohibitive factor. In
addition, it is recognised that the substitute prescribing of injectable heroin and methadone in the UK
appears to be a long-term treatment which may limit long-term cost-effectiveness.
The NTA will explore issues of cost in greater depth. However, cost factors indicate that commissioners
need to be able to ensure that the provision of injectable maintenance drug treatment does not
undermine the overall quality of care for all patients. Where adequate access to optimised oral drug
treatment options are not available to the majority of patients, it may be particularly difficult to
demonstrate this.
The potentially “high cost and low volume” nature of injectable maintenance drug treatment indicates
that it should be targeted at patients with high levels of need. These patients are, in any case, likely
to incur high levels of costs to health and social care systems.


          Inclusion criteria for injectable opioid maintenance

Clients should meet all of the following inclusion criteria in order to be eligible for injectable
opioid maintenance:
• The client should have a protracted history (> 3 years) of heroin dependence and regular
daily injecting.
• The client should be aged 18 or over.
• The client should be able to provide informed consent. This includes no active medical
or psychiatric condition impairing the patient’s capacity to provide informed consent
• The client should be willing to comply with the conditions of injectable opiate
treatment2, including:
• a treatment plan
• regular supervision and monitoring
• avoidance of persistent injecting in high risk areas (e.g. neck or groin veins)
• continuation of injectable treatment being conditional upon positive healthy response
to treatment (which includes other treatment elements in a package of planned,
co-ordinated care)
• diversion of the prescribed injectable drugs and “double scripting” being grounds
for discontinuation of injectable treatment.
• The client should first have received optimised oral maintenance treatment - an adequate
period (normally at least six months and for some this could be significantly longer) of
optimised conventional substitution maintenance treatment and associated package of care.
• There should be a persistence of poor treatment outcomes despite a current optimised oral
maintenance treatment episode. Indicators of poor outcomes may include:
• continued frequent (daily or almost daily) injecting of illicit heroin or other opioids
• patients at continuing high risk of the transmission of HIV, HBV or HCV to
themselves or others
• continuing injecting-related health problems (e.g. abscesses, cellulitis,
systemic infections), poor general health, poor psychosocial functioning and
drug-related criminality.
If the inclusion criteria are met injectable opioid maintenance treatment may then legitimately
be considered by the clinician, in consultation with the patient, key carers and the relevant
multidisciplinary team.
22

Monday, 4 March 2013

Getting Injectables Prescribed In The Uk

I'm currently in the process of helping a good friend who's having trouble with our local drug service. 

When I was using I know I could have done with someone on my side, advocating for me. So now I'm in a better position myself i thought I'd try and help.

So this is the situation, she is a long term user, around 20 years. IV heroin for most of it but speedballs, heroin and crack combined, for the last five years. Which I know from experience is a total bitch to kick. 
When I first started using, I used to hang with a guy that did both. He used to infuriate me because after hustling money, we'd go to score the heroin, I'd be chomping at the bit to use it! But this guy wouldn't do heroin without crack! Seriously, we'd have to wait around for hours sometimes for his crack dealer. He just point blank refused to do just the heroin and I just didn't get it! .... Fast forward 15 years and now I get it! I fell into the speedball trap too towards the end. It really is difficult to do just the heroin. It's just not the same. 
It's difficult to explain if you haven't experienced it, it's like toast without butter, or tea without sugar. Haha

It obviously also makes it that much harder to stop, you have a double whammy addiction!
I read somewhere about the physiological side of it. IV heroin or IV crack, alone, obviously induce a huge dopamine release, which gives the high. 
Put the two together however and the dopamine release is around 400% more!
It's an awful addiction to have, at least with just heroin, psychologically, you're on a pretty even keel. Yeah you have ups and downs, when you're sick and skint you feel crap but trust me, once you've been on speedballs you appreciate the difference. The crash after a day of using is just awful. It used to take me a week to recover from a speedball binge. Not even wanting to talk to anyone else, physically feeling awful but the psychological side of it is like nothing else. Well, maybe like an amphetamine come down,.. a bit..
When it's time to stop, you're not only battling cravings and physical symptoms of normal opiate withdrawal, you get the extra fun of cocaine cravings and withdrawal! Cocaine cravings are pretty intense on their own!
Like I said, double whammy! .... Why did you think it was a good idea to try a speedball again? ;)

So anyway, my mate is an old school addict. Been at it a long time, been in and out of rehabs and programmes. Spent the majority of her addiction on methadone, 180mg at the highest. In drug service terms anything over 60mg is classed as an 'optimised' dose. 60mg is believed to be the minimum to achieve a 'therapeutic effect', the 'optimised dose'. 
This has changed over the years, it wasn't too long ago that 60mg was considered a high dose!
Incredibly, in the United States, doses of up to 500mg daily aren't unheard of.
The most I have ever heard anyone being in here was 250mg. 

She tried subutex but didn't get on with it. Some people just don't get on with buprenorphine. It's a very different drug to methadone and heroin, pharmaceutically and subjectively. It's a semi-synthetic, partial opiate agonist/antagonist. 
It can feel quite 'chemically' to some people.  If you're used to full agonist opiates like heroin or methadone, the crossover to subs can be difficult. 

Right now she's frustrated with her treatment, she feels as though they have given up on her almost. A 'lost cause' .. It's very sad actually, this girl is an amazing person, really creative and kind. I've known her a long time, she's a little like me I guess, in that she's not really what you'd class as a 'junkie'. Having worked and supported herself, her kids and her habit most of her life. 
Like me, getting caught up in opiates using them almost like a sticking plaster, to deal with emotional pain. Opiates are great at numbing those painful memories some of us damaged people have. They were almost a natural progression for me, I'd spent most of my teens struggling with feelings and emotions that I just didn't have the tools to deal with. 

She's currently under the care of our local specialist addiction unit, at the hospital. This is where they send the people that don't respond well to traditional treatment, maintenance scripts which can be given by a key-worker at a community drugs service. 
They are, by definition, there to provide a specialist service, in my eyes you would think that that involves using a wider range of medications and psycho-social interventions like psychotherapy and family counselling. 

About a year ago, while I was still there actually, the budget was slashed.
Lots of NHS services were cut, obviously addiction services are an easy and obvious target and therefore one of the first to feel the pinch. 
The consultant that ran the unit for years was fantastic, I've written about her before I think. A really amazing, caring doctor. 
Part of the cuts included her having to incorporate the alcohol unit into the drugs unit. Splitting her time overseeing both units and pulling back on direct patient contact.  She wasn't prepared to make this compromise and ended up resigning, it was a travesty actually and makes me mad to this day. Things at the SAU really went downhill after she left. Every week I'd hear clients moaning in the waiting room, keyworkers would change from week to week, it became impossible to see a doctor and you could just tell that most of the staff couldn't really care anymore, they'd be out the door by 4.30 whereas in the past stayed til gone five.

Rather than clients seeing doctors, nowadays everyone sees a keyworker, no matter what their needs or level of priority. The keyworker is like the liaison between the client and 'the team'
The team consists of registrars, keyworkers, one psychologist (to cover every client), the consultants, the manager, nurse and various other workers. They meet weekly to discuss the clients. 

This may seem a sensible idea, and certainly streamlines things, but at what cost?
I know for me, when I was still there, I just felt a total lack of care or even interest. I had a different keyworker every appointment at one stage. They were obviously temporary agency staff, with no specialist training in the drugs field. One lady In particular was so obviously uninterested in me I played around a little and told her I was injecting benzos and that I was self harming again. To see her reaction. There was none.. She just wrote it down and moved on. I don't know what I was expecting really, maybe 'are you ok?' I guess..

Back to my mate.. She asked me to look up the government guidelines for injectable opiate prescribing. 
I have an interest in this too because I was looking into it for myself before I stopped using. 
It's a bit of a grey area, it's not a common practice, but technically it's possible to get an injectable script. The studies looking at injectable vs oral prescribing show positive outcomes, there is plenty of evidence from Europe, we all know about Zurich's incredible results with 'needle park'. They had a huge and very visible heroin problem some years ago, addicts would (infamously) stand out in the open, injecting eachother. 
They rather bravely, implemented an injectable opiates policy. Set up a clinic where addicts could go and get a legal, safe and regular supply of heroin. There were conditions attached of course, the addicts had to attend the clinic twice daily and inject in front of staff where they could be monitored to ensure they were injecting safely and to stop overdoses. Incredibly they cut their new addict numbers by around 80%. By taking the 'glamour' out of IV drugs, they essentially stopped people wanting to start using. They have similar places in Canada although these are just safe spaces to inject, with staff on hand dealing with OD's and to offer safer injecting advice. They don't prescribe here just supervise. Many many lives have been saved and local HIV and Hep C rates have dropped. 
Portugal have recently decriminalised the use of drugs, where before an addict would be punished through the courts and prison system, they started instead to offer them a place in rehab, or opiate replacement therapy. Again, they have proven the concept and cut drug related crime dramatically.
The glaringly obvious point here is that people will use drugs wether they are illegal or not, criminalising and punishing people for using DOESN'T WORK. Putting programmes and systems in place to help drug users is the only way to make a real difference. 

Although I don't personally need medical treatment anymore, it's not long ago that I did, and I feel strongly about the UK's and the rest of the western world's outdated and useless drug policies. The 'war on drugs' hasn't, and never will, work. 
I'm hopeful that things will change though, there is a small but rapidly emerging worldwide movement towards the decriminalisation of drugs. 

UK drug policy does allow for the off label prescription of injectable opiates for addiction. 
A home office licence is required to prescribe diamorphine though and there are only around 90 doctors that hold one. 
No licence is required to prescribe methadone amps though.
I feel my mate is a good candidate for injectable prescribing, after reading the NTA and NICE guidelines she fits the criteria. The only other things in the way are practical things like being able to demonstrate good injection technique and having good venous access. It's also necessary to monitor people closely who start this treatment. Especially during induction. It may not be logistically possible to prescribe at your local unit and this will have an impact on their decisions to provide injectables. 
Essentially though, the final decison rests with the prescribing doctor.  it literally is as simple as the personal prejudice, preference, experience and maybe even the whim, of the consultant. 
If you can demonstrate that you fulfil the criteria and you can show a good case for a realistic reduction in harm and improvement in illicit drug use, then there is really nothing stopping you pursuing it. 

Cost is another major factor, we all know oral methadone is cheap as chips. As low as 20p per dose. 
Currently there are around 5000 addicts receiving injectable methadone and around 450 diamorphine. Most of these people have been on it long term and were often inherited patients to the new doctor. Injectable scripts account for 80% of the total cost for methadone prescriptions.

Maybe some of you will think that I'm wrong. And that addicts shouldn't be given injectables. Maybe you're right. I just feel we should be given the option, if it works then all the better. 
As I keep saying, addiction is a complex, difficult issue, it is not a 'one size fits all' problem and treatment should be tailored to the client. Utilising all the treatment options, including medications. 

Trial results show a large amount of people either coming off opiates altogether or achieving a significant reduction of illicit drug use. That can't be a bad thing no?
If people aren't needing to commit crimes to get their drugs anymore doesn't society in general benefit?