New versions of drugs are constantly being developed and trialled, including injections of naltrexone and buprenorphine that can last up to six months, as well as a rapidly dissolving buprenorphine wafer, now approved in the UK as Espranor. It hasn\u2019t always been the case, but opioid substitution therapy is now accepted as a key instrument in enabling recovery. Having got this far \u2013 and despite the ever-present threat of cuts \u2013 is improving choice the next key step, asks DDN. Although divisions inevitably still exist, and probably always will, we\u2019ve come a long way since the sector was polarised by those bitter harm reduction versus abstinence arguments, with concerns over budget reductions and the austerity agenda perhaps helping to focus minds on the bigger picture. A significant step on this journey was the NTA\u2019s 2012 Medications in recovery report (DDN, August 2012, page 5), which has come to be seen as a landmark document. A fundamental re-examining of the treatment methods and objectives that can lead to recovery, it concluded that while \u2018entering and staying in treatment\u2019 and \u2018coming off opioid substitution treatment\u2019 (OST) were undoubtedly important indicators, they did not constitute recovery \u2018in themselves\u2019. Delivered properly, OST had \u2018an important and legitimate place within recovery\u2019, providing as it did a platform of \u2018stability and safety that protects people and creates the time and space for them to move forward,\u2019 it stated. What was also vital, it stressed, was to focus on broader support and make sure that OST is always delivered in line with clinical guidance. Shortly after the report\u2019s publication, Professor Oscar D\u2019Agnone \u2013 at the time clinical director of CRI, and now medical director of London\u2019s OAD Clinic \u2013wrote a DDN article expressing hope that the report might help put an end to the false dichotomy between abstinence and prescribing and bring about a situation where services would simply choose what worked best from a range of interventions (DDN, September 2012, page 23). Prof Oscar D'Agnone: 'We\u2019ve been witnessing massive reductions in treatment budgets... the recent rise in death rates is probably related.' Nearly five years on, he feels it \u2018was positive to move from a strategy based only on harm minimisation to a recovery-focused one that included harm minimisation,\u2019 but that the creation of that ideal treatment landscape has been hampered by budget cuts. \u2018Over the last couple of years we\u2019ve been witnessing massive reductions in treatment budgets, which has had massive implications for treatment and implementing recovery strategies,\u2019 he says. \u2018I think the recent rise in death rates we\u2019re seeing is probably related to these policies, and not just to aging populations.\u2019 Those groups are simply the most vulnerable to these policies, he believes. \u2018You have a lot of people over 55 or 60 who have been on prescriptions for years and they have been removed from those prescriptions for reasons that I don\u2019t think are related to the recovery agenda, but to budget reasons.\u2019 Indeed, the Medications in recovery report concluded that, while people should not be \u2018parked indefinitely\u2019 on substitute drugs \u2013 and that all prescriptions should be regularly reviewed \u2013 neither should arbitrary time limits be imposed. Is the sector more accepting of that position now? \u2018Well, I think those statements are made from Mount Olympus, if you like \u2013 people on the ground are seeing different things,\u2019 he states. \u2018In my clinic, I have 48 people over 60 and eight people over 70. You can argue that these people should not be on high methadone or other prescriptions, whether that\u2019s right or wrong, but what I\u2019m saying is these people are alive and kicking and I\u2019ll keep them on the same dosage. If I impose a reduction on them, they\u2019ll start dying. And that\u2019s what we\u2019re seeing in the north west of England and other areas.\u2019 It\u2019s argued that time limiting OST not only threatens people\u2019s ability to sustain their recovery but also risks increasing blood-borne virus transmissions, drug-related deaths and more. Would he go along with that? \u2018Absolutely,\u2019 he says. \u2018It\u2019s for the patient to say when the time has come to stop, not for me to impose that. The problem is that a heroin user nowadays is an old adult \u2013 they\u2019ve been on heroin for a long time. Setting time limits for these patients is very, very risky. All these considerations about time limitations are based, basically, on budget reasons, not clinical reasons. There\u2019s not a shred of evidence that time limiting will produce better outcomes.\u2019 Ultimately, choice is vital when it comes to prescribing, he believes. \u2018At my clinic I have patients coming from the public sector and the private sector, and we have a more open-minded view \u2013 they have more freedom to discuss the medications they\u2019d like to take, and the doses. I\u2019m receiving people who are on 1.5mg of buprenorphine, and all they wanted to be is on 2mg, but they\u2019ve been told, \u201cno, you have to be on 1.5, and reducing\u201d. That\u2019s ridiculous, and it\u2019s putting people at risk.\u2019 As part of the quest to respond to patient need, new versions of drugs are constantly being developed and trialled, including injections of naltrexone and buprenorphine that can last up to six months, as well as a rapidly dissolving buprenorphine wafer, now approved in the UK as Espranor. As standard buprenorphine capsules can take between five and ten minutes to dissolve \u2013 clearly far from ideal for supervised consumption in a busy pharmacy or prison setting \u2013 it\u2019s hoped that products like this can help cut the drop-out rates for buprenorphine treatment, which currently stand at about 50 per cent within six months. \u2018We\u2019re finding administering Espranor takes about 30 seconds, so it\u2019s certainly a much quicker product than the generic hard compressed tablet,\u2019 says GP and substance misuse specialist Dr Bernadette Hard, who has been prescribing Espranor in her Cardiff-based service since January. While her service began using it in a criminal justice setting, they have since had some clients move their prescriptions to community pharmacies, she points out. \u2018Our main motivation for wanting to trial this new preparation was the challenges we faced around diversion and misuse, and we had around 30 people when we did the initial switch,\u2019 she says. \u2018The people that we felt were appropriately on buprenorphine and benefitting from it had a very positive experience with switching \u2013 they liked the fact that it dissolved quicker and they didn\u2019t feel they were being scrutinised, because if you are taking it properly but someone feels you might not be, that can be quite uncomfortable. Some pharmacists are really good and respectful, others less so.\u2019 Patient feedback The feedback on espranor so far has been very positive, she says. \u2018For those clients where we were always a little bit suspicious around their motivation for wanting to be on buprenorphine, some of them did struggle with the switch. Some found that \u2013 where they probably hadn\u2019t been taking their full amount before \u2013 when we switched them onto Espranor they had to reduce their dose because they were finding it a little too strong. One or two have actually said they used to get bullied for their tablets, so they\u2019d prefer to be on Espranor because they have fewer people requesting them, things like that.\u2019 So how important is choice in substitute prescribing generally? \u2018Well, we don\u2019t have many options,\u2019 she says. \u2018You can try and categorise via a patient\u2019s history who you think is going to do better on methadone or buprenorphine, and most of the time we\u2019re right about that. But not always, and some people just gel with one product and I think it\u2019s important that we respect that, in the same way we would in primary care. It\u2019s part of building a mutual relationship, where you\u2019re not just dictating to them.\u2019 The DDN Conference At the recent DDN service user conference, however, it was pointed out by user involvement activists that this is perhaps the only medical area where people don\u2019t always have those conversations about choice with their doctors (DDN, March, page 8). It can often be a case of \u2018here you go, I\u2019m giving you this\u2019. \u2018I would challenge that, actually,\u2019 she says. \u2018There are areas where we can sound quite paternalistic and also where we\u2019re being driven by budget, but that\u2019s not exclusive to substance misuse. I think it can sometimes feel that way in substance misuse because an awful lot of the way we deliver services is by its very nature patern\u00adalistic \u2013 because we\u2019re supervising people and so on. \u2018But I think more choice and more options is always going to be beneficial, and we have to get in there and use these things,\u2019 she states. \u2018I\u2019ve been on development groups and the like, and we can all sit around as experts and ponder how this is going to pan out and where it\u2019s going to be of most use, but sometimes you just need to use it \u2013 obviously in controlled way \u2013 to really understand where people are going to go with it.\u2019 This article has been produced with support from Martindale Pharma (now an Ethypharm Group Company), which has not influenced the content in any way.