Great article about addiction

Drug use is common, drug addiction is rare. About one adult in three will use an illegal drug in their lifetime and just under 3m people will do so this year in England and Wales alone. Most will suffer no long-term harm.

There are immediate risks from overdose and intoxication, and longer-term health risks associated with heavy or prolonged use; damage to lungs from smoking cannabis or the bladder from ketamine for example. However most people will either pass unscathed through a short period of experimentation or learn to accommodate their drug use into their lifestyle, adjusting patterns of use to their social and domestic circumstances, as they do with alcohol.

Compared to the 3m currently using illegal drugs there are around 300,000 heroin and/or crack addicts while around 30,000 were successfully treated for dependency on drugs in England in 2011-12, typically cannabis, or powder cocaine.

A powerful cultural narrative focusing on the power of illegal drugs to disrupt otherwise stable, happy lives dominates our media and political discourse, and shapes policy responses. Drug use is deemed to “spiral out of control”, destroying an individual’s ability to earn their living or care for their children, transforming honest productive citizens into welfare dependent, criminal “families from hell”.

This is a key component of the Broken Britaincritique of welfare and social policy advanced by the Centre for Social Justice and pursued in government by the CSJ’s founder Iain Duncan Smith in his role as secretary of state for work and pensions. However, the narrative has resonance far beyond the political arena and underpins most media coverage of drug addiction and the drug storylines of popular culture.

Most drug users are ..?

In reality the likelihood of individuals without pre-existing vulnerabilities succumbing to long-term addiction is slim. Heroin and crack addicts are not a random sub set of England’s 3m current drug users.

Addiction, unlike use, is heavily concentrated in our poorest communities – and within those communities it is the individuals who struggle most with life who will succumb. Compared to the rest of the population, heroin and crack addicts are: male, working-class, offenders, have poor educational records, little or no history of employment, experience of the care system, a vulnerability to mental illness and increasingly are over 40 with declining physical health.

The usual message. Imagens Evangelicas, CC BY

Problem cannabis use is less concentrated among the poor, but is closely associated with indicators of social stress and a vulnerability to developing mental health conditions.

Most drug users are intelligent resourceful people with good life skills, supportive networks and loving families. These assets enable them to manage the risks associated with their drug use, avoiding the most dangerous drugs and managing their frequency and scale of use to reduce harm and maximise pleasure. Crucially they will have access to support from family and friends should they begin to develop problems, and a realistic prospect of a job, a house and a stake in society to focus and sustain their motivation to get back on track.

In contrast the most vulnerable individuals in our poorest communities lack life skills and have networks that entrench their problems rather than offering solutions. Their decision making will tend to prioritise immediate benefit rather than long-term consequences. The multiplicity of overlapping challenges they face gives them little incentive to avoid high risk behaviours.

Together these factors make it more likely that, instead of carefully calibrating their drug use to minimise risk, they will be prepared to use the most dangerous drugs in the most dangerous ways. And once addicted, motivation to recover and the likelihood of success is weakened by an absence of family support, poor prospects of employment, insecure housing and social isolation.

In short what determines whether or not drug use escalates into addiction, and the prognosis once it has, is less to do with the power of the drug and more to do with the social, personal and economic circumstances of the user.

Heads in the sand

Unfortunately the strong relationship between social distress and addiction is ignored by politicians and media commentators in favour of an assumption that addiction is a random risk driven by the power of the drug.

It does happen. But the atypical experience of the relatively small number of drug users from stable backgrounds who stumble into addiction and can legitimately attribute the chaos of their subsequent lives to this one event drowns out the experience of the overwhelming majority of addicts for whom social isolation, economic exclusion, criminality and fragile mental health preceded their drug use rather than being caused by it.

Viewing addiction through the distorting lens of the minority causes policy makers to misunderstand the flow of causality and pushes them towards interventions focused on changing individual drug-using behaviour and away from addressing the structural inequality in which the vulnerabilities to addiction can flourish.

Until we re-frame our understanding of drug addiction as more often the consequence of social evils than their root cause, then we are doomed to misdirect our energy and resources towards blaming the outcasts and the vulnerable for their plight rather than recasting our economic and social structures to give them access to the sources of resilience that protect the rest of us.

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 

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 

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!

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

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?

Adulterated Heroin In Hackney

http://www.release.org.uk/heroin-warning-february-2013

Release has received reports of dangerously adulterated heroin circulating in the Hackney area. It seems to be wide spread among local 'shotters'/street dealers. It is medium dark and appears to run on foil but we have had a couple of reliable reports from users and their friends suggesting that it has an opiate-type rapid onset of action (by smoking) but within twenty minutes to half an hour observers became concerned about disorientation, confusion, loss of co-ordination and loss of memory in users. The reports also state that the initial taste is usual, but the after taste is ‘strongly chemical’.

We suspect that it may be cut with a benzodiazepine and/or possibly Gabapentin/Pregabalin. There is a chance the benzodiazepine of concern is Alprazolam, a very strong form of benzodiazepines, or a pre-operative hypnotic benzodiazepine Midazolam (where users appear to be knocked for a couple of days). Benzodiazepines and opiates are dangerous mix in general, with profound effects on the respiratory system, and these benzodiazepines are particularly strong. With regards to potential cut with Gabapentin/Pregabalin, these are again very strong drugs, used in treatment of chronic pain/epilepsy and there are reports that these in combination with opiates can cause the above effects seen in this potential new batch.

We saw similar adulteration in the heroin shortage of 2010 which caused greater problems afterwards, when there was a high risk of overdose with batches that were not cut as strongly.

A New Year..

My life feels like a merry go round sometimes. Only one that never stops to let you off!
Every new year and every birthday I promise myself 'not another year, this has to stop now and yet the next year here I am again, looking back at my own reflection with another years worth of lines and the beginnings of grey hairs.
I've been doing this ritual since I was seventeen. I guess things are better, im nowhere near as bad as I have been. Since my last Iboga flood I seem to have lost that obsessing for drugs thing. That's a relief and a novelty to be frank. I'm obviously not in the small percent of people that take Iboga and detox never to touch or crave drugs again.
I have to keep telling myself, it's not perfect but it's better. This time last year I was shooting crushed MST, plus heroin and crack on top. I do none of those anymore!
Actually, shooting the MST for so long has really left me with some quite scary health problems.

I wish I was better at taking my own advice sometimes. It's like I hear the words coming out my mouth when I'm trying to help others but I'm fucked if I can actually follow it myself!

I took a break from the big Facebook group I admin over the holidays. Since the creators and co admins, Cat Asche & Chris Bava died so unexpectedly last September in that awful car crash I've been trying to hold the group together. I was the only other admin in the group. I guess I felt responsible, and to a large extent, invested in the group. I've been a member for a few years, I've made some amazing friends there too, people that I'd say I'm closer to than people in my real life. I've witnessed some incredible acts of kindness happen there. From letting people stay at others homes, gifting ibogaine, donating towards members in hardship and just general support really. I mean there have been quite a few hairy moments with in fighting and tantrums but on the whole I love them all. Since Chris & Cat died the group has been in turmoil really. People jostling for a new position in the group, a lot of 'well I know what Chris and Cat would have said/wanted/done/agreed/disagreed with' etc.. Almost like a popularity contest at times. I've struggled at times because by taking over the role I seemed to automatically make a load of enemies. People that I've never met or spoken to suddenly abusing me and slandering me. All very bizarre and quite hurtful really, it's a strange thing, being an admin in such a large group of very bold personalities. It seems people view me as 'in authority' or something. I've been accused of being egotistical and power hungry, of only being interested in telling everyone I'm gay, of hating women and wanting to turn the group into my private domicile. Chris was excellent at refereeing, when arguments arose it often only took a paragraph from Chris and everyone would settle down. Because he was so patient and endlessly compassionate, he was able to placate people and settle any disputes whilst simultaneously being fair at all times, to both parties. He was wise, he cared and he had the time to spend every day having multiple pm's with people. There's no way I could ever love up to that! I wouldn't even try. In the weeks after they passed I spent days worrying about how best to continue the group, I came to the conclusion id need co-admins to help with the workload, vetting join requests and general day to day stuff. Chris used to pm new requests just to check them out briefly, the group has a huge proportion of silent members. I did the same, this would very often end up in long conversations about ibogaine and dosing and recovery, it really is a lot of work behind the scenes. Chris very rarely censored comments or booted anyone, it took a lot for him to remove someone. The problem is that he is obviously no longer with us, it seems that the previous light handed, laid back method of adminship no longer works. People seem to now think it's ok to troll, to offend other members with name calling and get away with it. In my opinion, part of my role is to keep the group safe and a place where anyone can ask for help. I did notice a drop in the amount of these kind of posts and a rise in the obnoxious, silly ones. This is why I think I might need to discuss with the group the possibility of some new small rules about abusing other people. It's not nice and it's not fair. There was an issue a few weeks back, a member that had been in the group a long time but rarely contributed was becoming abusive to a new member. She was obviously high, it was escalating, she was offering bad advice and offending other members so I stepped in and booted her. I pm'd her to say 'I took you out for 24 hours, your welcome to come back when you've calmed down' ... Well, the abuse I got was unreal, I was a cunt and a faggot, a women hater. I mean really vile stuff. Anyway, she went on to slander me in her group but that's another story! I thought it had blown over until people kept bringing it up in my group 'Sid booted her too early, I wasn't finished with her' etc.. This was just the most recent in a long line of unfair comments aimed at me, comments I'd let go for the sake of peace, and that as an admin I felt I should be somewhat impartial. That's why I left anyway, it was the straw that broke the camels back so to speak. It was quite liberating actually, I felt free of the responsibility for a short time. People forget I think that I'm only a few months into recovery myself, I'm not the strongest person in the world and I don't have a thick skin (all necessary traits for a good admin apparently!) ... I heard the odd report of what's been going on, I was really quite shocked at the latest drama though! One of the older members had taken it upon herself to start some group polls. With the following questions posed: Should we boot out the current admins.? Another one asking: Should we all get a say in group decisions? .. Now, there is a reason the group isn't asked to vote on things like this, it would be a nightmare for one! 600 people voting Everytime a group picture was changed, or which posts are pinned. It would be silly, Chris himself said as much, 'the ISC is not a democracy, if you don't like it, leave'. I've no objection to the group having input but not to that extent. It's a closed group with admins, not an open group where everyone has equal privileges. Anyway, the polls flopped, the votes against her were 18 to 10 I believe, at which point she herself deleted them! ... The next thing we hear, she's started her own 'secret' group called 'ISC2'! With the 'about' saying 'this is the new ISC, for those jumping ship as its now falling apart' .. She then added 60 odd people without asking them, included in that list were Cat and Chris themselves and Chris's elderly mother! The whole thing is sick actually. I've no problem at all with splinter groups, nor did Chris! He in fact encouraged people to, and would join them and contribute! My issue is with the underhand and nasty way she's done this. It's so disrespectful to Chris and Cats memory, and legacy! Right now people are practically begging me to come back, I have rejoined, lets hope things get better. The ISC used to be such an amazing group and it would be very sad for the few louder members, claiming to be the majority, to destroy it.

That's all for now! I needed to vent.

Happy new year to you all!