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?