Breaking Ties

When prescribing regimes are preventing service users from moving on, should we be looking at new options? DDN reports

‘What makes me angry is that they’re treating every drug user as potentially stupid and can’t look after their own welfare, or potentially as a criminal because you’re going to divert your tablets.’

Marcus is talking about the frustrations of being back on supervised consumption. After giving a ‘clean’ sample at the drug service he was put straight onto a weekly pick-up of 6mg of buprenorphine, ‘which was brilliant’. But he ‘started to have a wobble’ about three months ago and began using a couple of times a week. He went back to the drug service and was honest with them: ‘I said this is happening, can I increase my dose?’

The answer was yes, but it was only when he reached the chemist that he realised he had been put back on supervised consumption, having to travel some distance each day to collect his buprenorphine. ‘I accept part of the blame for this – I should have read the script,’ he says. ‘But she should have gone through it with me, she didn’t say a word.

‘I feel as though I’m being punished for using and being honest,’ he says. ‘She’s saying it’s for my own safety. I said, “I’m a 48-year-old man, I can look after my own safety and I’ve never given anyone any reason to believe I’m diverting tablets”. But no, their policy is, “start using again and you’re back on supervised until you can give two clean samples”, and that’s it.’

It makes it very difficult for him to move out of the area, he explains, and going back to the same place brings pitfalls that he had been able to avoid. He sees the same people every day, people ‘sorting deals out’ at the drug service and the chemist. It’s very hard to get away from. ‘I’m seeing people all the time – I know it sounds pathetic, but you only need the tiniest trigger with heroin.’

So what’s going wrong when a highly articulate person feels like they can’t communicate with their drug service? ‘I don’t know whether they have hard and fast rules or guidelines, but if they’re rules then they’re wrong, and if they’re guidelines they should be flexible,’ says Marcus. ‘I don’t feel like I’m invested in my own treatment at all. They are treating me, and that’s it.’

We talk constantly about the stabilising effect of prescribing in helping service users to get back into work, but are we thinking enough about cases where it’s having exactly the opposite effect? Rebecca (not her real name) has been ‘using a bit’ on top of her script, but she can’t tell her drug service the truth about this because they’ll put her back on supervised consumption – and if this happens, she’ll lose her job and her family’s only source of income.

‘They’re putting you in a position where you can’t work,’ she says. ‘I’ve had people say to me in services, when I’ve gone in for treatment, “you need to think what your priorities are”. I’ve said I can’t come to a group every morning, I work full-time. My priorities? Well, a roof over my head to be perfectly honest with you.

‘So you’re pushed out of treatment from day one. It makes life doubly difficult. They don’t expect you to be working and they make very few concessions for you.’

It was these issues among their own service users that made WDP look at flexible dosing regimes – they have just become the first state-funded treatment provider to offer a prolonged-release version of buprenorphine in England and Wales.

According to a study by Haight, Learned, Laffont et al, published in The Lancet (February 2019) taking buprenorphine through an injection every four weeks can offer a viable treatment option for those who find it difficult to attend treatment or keep to a regular daily dose – and will also be a good option for when there are children in the home who might be at risk of taking stored medication.

Findings comments on this study that ‘extended-release injections would seem to have their greatest potential among less stable patients – those unlikely to take daily doses and perhaps even less likely to regularly attend a pharmacy or clinic for consumption to be supervised.’ They also quote Professor Sir John Strang’s comments that this could be a ‘game-changer’ in opiate addiction treatment.

A further study, published by Neale, Tompkins and Strang in the Harm Reduction Journal (April 2019), supports the idea that these prolonged-release formulations could be beneficial to patients ‘who wanted to avoid thinking about drugs and drug-using associates, wished to evade the stigma of substance use, and desired “normality” and “recovery”.’

Dr Arun Dhandayudham, WDP’s joint CEO and medical director, and Tohel Ahmed, service manager of R3, WDP’s service in Redbridge, had keenly followed the trials in other countries, such as the USA and Australia, and felt that this could help to expand treatment options. Encouraged by the reported success of subcutaneous buprenorphine injections (depots), they established a working group, including WDP staff, Redbridge commissioners and a local pharmacist. Together they developed clinical protocols to enable the new treatment to be prescribed.

Beginning with a pilot project in the London borough of Redbridge, they recruited six service users to try the depot injections. The mixed-sex group of participants includes some who are employed or self-employed, and three of them have children.

The staff involved in the pilot have already noticed the benefits for participants in being able to carry on with their lives without being tied to visits to the chemist, with everything that that entails.

‘Stigma is something our service users experience every day, from themselves and others,’ says Dr Della Santhakumar, clinical lead at R3. ‘This option gives a break from it and offers a taste of normality. This can be a very powerful tool psychologically to move forward in their recovery journey.’

The research goes on. WDP’s Innovation and Research Unit is designing a project to evaluate the effectiveness of buprenorphine depots compared to traditional treatment regimens – but in the meantime the success of the pilot is leading to expansion of the programme to more service users, and across other locations.

‘This has been a great example of partnership working,’ says Dr Arun Dhandayudham. ‘It will support good clinical outcomes and give service users greater autonomy to focus on other aspects of their lives.’

How’s it going?

Feedback from the pilot’s participants has shown reasons for optimism. But as always, every case is complex and it’s still early days.

When Nicola, aged 42, joined the trial she felt unsettled on a sublingual dose. Living at home with two daughters, she felt that the depot dose could make life easier and three weeks on she says she feels ‘alright’ and is not tempted to use on top. While she doesn’t miss daily attendance, she has raised issues around support that management are addressing.

Paul, aged 35, also felt unsettled before the change in treatment, but has felt substantial improvement after a month. He lives with and works with his father and describes the change as ‘brilliant’.

Simon, aged 29, lives in a shared house and has occasional work. On the new dose for three months, he says he feels better for it. He hasn’t experienced withdrawals but smoked heroin twice when he had been drinking alcohol. He says he feels ‘a better person’ for the change of regime.

David, aged 43, lives in sheltered housing and was struggling before starting the new dose. Initially he was ‘not 100 per cent’, but a couple of months on he says he ‘feels fine’ and is glad not to be tied to the pharmacy every day.

Names have been changed to protect identities