This series of three articles series examining the past, present and future of buprenorphine in the treatment of opioid dependence ran in DDN Magazine. They are all available below. Skip to part one 'Filling the prescription' The surge of buprenorphine prescribing during the COVID-19 pandemic triggered a reflection of its journey, and with the recent introduction of long-acting injectable buprenorphine Dr Georges Petitjean and Deanne Burch question what its future is within drug treatment services. Skip to part two 'Weighing up the benefits' where Dr Georges Petitjean and Deanne Burch explore different buprenorphine preparations, its use during the COVID-19 pandemic and its safety and cost in comparison to methadone. Skip to part three 'The long game' in which Dr Georges Petitjean and Deanne Burch look at the opportunities, and challenges, presented by long-acting Buvidal injections and Dr Jan Melichar discusses the Welsh roll-out of Buvidal. ------------ Filling the prescription This article is the first in a series examining the past, present and future of buprenorphine in the treatment of opioid dependence. Buprenorphine is a medication used in opioid substitution treatment (OST), and it has also been used extensively for the management of pain. The surge of buprenorphine prescribing during the COVID-19 pandemic triggered a reflection of its journey, and with the recent introduction of long-acting injectable buprenorphine we question what its future is within drug treatment services. Development In the USA, the Committee on Drug Addiction was created in the 1920s where it studied the morphine molecule, searching for medicines which would not cause addiction. It was hoped that they would find a medicine which could be used in the place of opium based medicines. The search to find a non-addictive analgesic began in the 1920s following increasing concerns that opioid addiction was resulting from iatrogenic prescribing. The opioid agonist methadone was initially developed during World War II and it was prescribed minimally in the 1950s. Due to the lack of agreement on its safety and its inability to produce the desired effect without addiction, the search for opioid antagonists commenced. The concept of ‘substitution treatment’ was first developed in response to the opium and morphine addiction epidemic in the USA. It was fully recognised by then that even if a safe and side-effect free alternative was discovered, the addiction problems countries faced would not be resolved in totality due to the complex factors that influence addiction. Therefore, it was suggested that antagonists may assist in managing the problems associated with addiction, rather than completely resolving them. During the 1960s there was a shift from attempting to cure addiction to finding a medicine that alleviated some of the risk. Naltrexone, an opioid antagonist, was produced in the 1960s but only used as a supplementary treatment from the 1980s. Discovery In the mid-1960s buprenorphine was discovered. Longer acting relapse prevention methods such as antagonist depot injections were studied in the 1970s, while researchers also explored whether naloxone could be added to opioid medicines, and it was around this time that the search for a medicine with both antagonist and agonist properties began to really accelerate. Methadone maintenance was largely looked upon as a solution to treating opioid-dependent veterans and crime in the USA. Despite its support, its limitations were recognised fully. By the late 1970s it was assumed that buprenorphine could effectively replace methadone as a treatment in opioid dependence because of its low misuse potential – essentially it was thought to have the benefits of both methadone and naltrexone but fewer drawbacks. Treatment Although sublingual buprenorphine was launched from 1982 for analgesia, it wasn’t until 1998 that it was licensed for the treatment of opioid dependence in the UK as an alternative to methadone. Despite the support buprenorphine gained as having the potential to be the next major medicine for treating opioid dependence, it took three decades to be fully approved and utilised in drug treatment services. The development of buprenorphine met with political and social challenges and as an additional option for opioid substitution treatment it has had mixed responses from patients. The dismantling of the barriers that can exist for opioid substitution treatment, as seen with the widespread use of buprenorphine in France, have led to innovative ways of tackling overdose, treatment and retention rates. In the next article we will look at the introduction of different buprenorphine preparations, its use during the COVID-19 pandemic, and its safety and cost in comparison to methadone. ----------------- What do patients think about buprenorphine? We asked some patients what their experience was of being prescribed buprenorphine and received both positive and negative feedback Positive experience of buprenorphine ‘Buprenorphine is far better than methadone – when I came off it I had to go through six weeks of hell. I felt like an old man, with aches and pains, hallucinating. I did a 14-day detox. When I came off buprenorphine it was much easier, just a few days of restless legs and that was it If I’d have known what it was like coming off of methadone I’d rather have just stopped off the heroin. Methadone is worse than heroin itself. I went down to 2mg on methadone – three weeks after coming off methadone I felt so bad I took a total of 100mg diazepam, and they didn’t even touch the sides.’ ‘You feel like an old man, the pain is unbelievable – 18 years ago this happened, they kept me on maintenance.’ ‘I came off buprenorphine a few times, no issues like I said, just restless legs the first night, then the second night a full night’s sleep. I was a lot younger back then, the helpful thing is to exercise.’ Negative experience of buprenorphine ‘I didn’t get on with buprenorphine at all, although most people I know have got on with it. The first time they didn’t bring me down to 30 mg of methadone before I switched onto it, I was on 70mg. I left it two to three days to be in withdrawal, took one and then I was ill, I was actually going to a job interview that day – 20 minutes before I went for the job interview it felt like a super cluck. I had to go out and get something.’ ‘I tried to get onto buprenorphine three times. This was seven or eight years ago.’ ‘I prefer the methadone. It’s something mental I suppose, I’ve been on it for so long.’ ----------------- Buprenorphine Chemistry Buprenorphine is a partial agonist at the mu opioid receptor and an antagonist at the kappa receptor: μ-opioid receptor Buprenorphine has a very high affinity, a low intrinsic activity, and a slow dissociation at the mu receptor. It has unique and clinically desirable pharmacological properties: lower misuse potential, milder withdrawal symptoms on dose reduction than methadone and a ceiling effect at higher doses (meaning that an overdose of buprenorphine is less likely to cause fatal respiratory depression than an overdose of a full mu opioid agonist like methadone). Buprenorphine produces a dose-related blocking of drug ‘high’ from ‘on-top’ use of heroin, making it particularly appealing to well-motivated patients. However, if taken too soon in opioid-dependent patients, buprenorphine can displace heroin and other opioids from the receptors, yet not provide the equivalent degree of receptor activation, thereby leading to a rapid drop in opioid effect and the onset of opioid withdrawal symptoms (‘precipitated withdrawal’). κ-opioid receptor The high-affinity kappa receptor antagonism of buprenorphine is involved in reducing stress-induced drug-seeking behaviour. Also, kappa antagonism has demonstrated antidepressant properties. ----------------- The French model In France in the 1980s, the widespread off-label use of buprenorphine was being used to treat addiction. In 1995, it was the first country to approve the use of buprenorphine for the treatment of opioid dependence. There was an acknowledgement at the time of increasing levels of overdoses and it was suggested that the majority of people who were opioid dependent were not receiving treatment. GPs were enabled to prescribe buprenorphine and they adopted a low threshold, far-reaching approach. This approach incorporating GPs had the benefit of normalising addiction treatment into mainstream care. Financial barriers were reduced for GPs and patients. The outcomes were: • The number of people treated for opioid dependence with buprenorphine vastly overtook the numbers prescribed methadone. • The majority of buprenorphine treated patients in Europe were in France. • Overdoses reduced enormously. • Pharmacists saw an increase in retention into treatment rates. • HIV infections in people who injected drugs fell dramatically. • However, France saw a higher number of patients injecting their buprenorphine, particularly when lower dosing was used. The French model is an example of where reducing the financial, procedural and stigmatising barriers associated with treatment has resulted in positive outcomes for patients. ----------------- What did clinicians think about buprenorphine? We asked Dr Emily Finch, vice chair of NHS APA, vice chair of the Addictions Faculty at the Royal College of Psychiatrists and clinical director at South London and Maudsley NHS Foundation’s Southwark Central Acute and Addictions Directorate. When buprenorphine first came to the market as an addiction treatment option in the UK, what were the fears and expectations in drug and alcohol services? Discussions were dominated by cost when it first came in. It was initially much more expensive. So there were many thoughts about who was most suitable for it – essentially we were rationing it. The first person I gave it to went into precipitated withdrawal. It probably made me very cautious. Over time prescribers and service users gradually understood the need to be in withdrawal when given the first dose. There were concerns about the difficulties supervising it. It took longer. It was a time when methadone maintenance was not very old in England and most methadone was supervised. At that time we also had lofexidine which we were using for detox. Service users did not like it at all initially. We were sceptical about the evidence from France, where methadone was not an option, and the US literature where it was introduced because they couldn’t use methadone in ‘office based’ settings – effectively primary care. We knew about its reduced overdose potential but we weren’t that convinced. In your opinion, has buprenorphine reached its initial expectations of being a safer and preferred alternative to methadone? I don’t think that was the initial expectation – perhaps by the drug companies, but not by most UK prescribers. It has revolutionised opioid detox and has been successful where drug use may be less chaotic. That is its biggest impact – it is safer but only if the service user will take it. All of my prescribing and the policies I have written have emphasised offering buprenorphine as an option equal to methadone – maximal patient information and influenced by the NICE technology appraisal. Often this means prescribing buprenorphine first, then if that is not successful they’re prescribed methadone. How do you explain that buprenorphine prescribing has not become the ‘gold standard’ in opioid substitution therapy, as it was originally predicted to be? I don’t think it was predicted to be the ‘gold standard’. Perhaps it is because it doesn’t make service users intoxicated. So, they stop taking it. The fact that they need to be in withdrawal for induction is a barrier. Other barriers can be the perception that you cannot ‘use on top’ and the fear of not being able to use. Additionally there has been diversion of buprenorphine in prisons because of the inability to supervise it and the difficulty in induction for many. This can reduce retention rates. The reality is that many people who use drugs in the UK carry on ‘using on top’ of their opioid medication. Does that say something about the adequacy of the rest of the treatment system? ----------------- Dr Georges Petitjean is the substance misuse medical lead for Inclusion, part of Midlands Partnership NHS Foundation Trust. Deanne Burch is the hepatitis C elimination coordinator for the NHS Addictions Providers Alliance (NHS APA). Inclusion: www.inclusion.org The NHS Addictions Provider Alliance: www.nhsapa.org The authors have not received any financial or other support from pharmaceutical companies and the articles are their own opinion. See the February 2022 issue for part two. In the second of a three-part series, Dr Georges Petitjean and Deanne Burch explore different buprenorphine preparations, its use during the COVID-19 pandemic and its safety and cost in comparison to methadone. Different forms of buprenorphine have been developed since its introduction into the drug and alcohol field as an alternative to methadone. Transdermal patches were launched in Germany and Switzerland in 2001 for analgesia, and buprenorphine/naloxone sublingual tablets (also known under the brand Suboxone) were authorised for marketing in 2017 in Europe. The buprenorphine contained within buprenorphine/naloxone is absorbed sublingually but the naloxone component has a 5-10 per cent absorption, essentially leading to a low clinical effect. However, if the buprenorphine/naloxone is injected this would enable a dose of naloxone to induce opioid withdrawal, providing a reduced potential for misuse. Advantage In 2017 buprenorphine lyophilisate (also known under the brand Espranor) was introduced to the UK market. Buprenorphine lyophilisate had the advantage of dissolving on the tongue, enabling quicker supervision by pharmacists and making diversion less likely. Many drug treatment services switched to prescribing buprenorphine lyophilisate amid the increasing cost of sublingual buprenorphine in an effort to manage budgets. The increased bioavailability of buprenorphine lyophilisate presented an initial challenge for drug treatment services who wished to switch patients from sublingual buprenorphine, as the products were not believed to be dose interchangeable. Methadone domination Despite there being good evidence that buprenorphine is as effective as methadone as a form of opiate substitution treatment (OST) for maintenance and detoxification, and its perceived safety, rates of methadone prescribing continue to dominate those of buprenorphine within UK drug treatment services. In regards to its safety, buprenorphine – like methadone – can cause respiratory depression leading to death, but this is more common when buprenorphine is used in conjunction with other sedatives such as alcohol or benzodiazepines. During the early months of the COVID-19 pandemic drug services closed to minimise the risk of infection within a vulnerable population. Many utilised alternate forms of assessment via telemedicine, and were unable to use drug screens to provide objective evidence of opioid dependence. The result was the rapid increase of sublingual/lyophilisate buprenorphine prescribing due to the perception of increased safety upon initiation. The ability to prescribe buprenorphine in this context enabled service users to continue to receive opioid substitution treatment. Transformation Rapid changes in practice came with the initial stages of the pandemic, such as the limitations on face-to-face assessments and relaxed daily supervised consumption arrangements at pharmacies. This period brought mixed reports from clinicians and patients, with many patients self-reporting reduced heroin use and more stability on prescribed opioid substitution treatment, whilst many clinicians spoke of concerns around risks. The transformation of buprenorphine into different preparations has given an opportunity for drug treatment services to respond effectively to changing and emerging risks to patients, but also to organisations. During the COVID-19 pandemic buprenorphine’s safety profile was utilised to ensure the continuity of opiate substitution treatment for patients in what was an anxiety-provoking time for clinicians and organisations alike, and lessening the risks associated with not being on treatment. 2019 saw the introduction of the long-acting buprenorphine injection, Buvidal, which has not yet been fully embraced within all drug treatment services nationally. We examine its place in the future of opiate substitution treatment in our third instalment. Key questions We asked several experts about their views on the differences in cost, the uptake of buprenorphine lyophilisate within treatment services, and the role of the commissioner in supporting the cost-effectiveness of treatment. What were the differences in cost that presented challenges for drug and alcohol services? Around 2019 there was a significant increase in the drug tariff costs for buprenorphine of up to 800 per cent, while methadone costs remained relatively stable. During the same period a number of services saw a reduction in funding received from commissioners. Affected services needed to review their service model in order to continue to serve the population effectively and give service users a choice on the pharmacological treatment offered. The alternative would have been to employ strict rules on buprenorphine prescribing pathways such as time-limited treatment, having the drug as a second choice on formularies – restricting service user choice – and having stricter rules on testing for illicit substance use. One solution adopted by a number of services was to implement a buprenorphine pharmaceutical rebate scheme, the application of which did not influence prescribing as the therapeutic intervention already had a place in clinical practice. This provided stability in the cost of the drug, allowing services to manage drug budgets as well as providing significant efficiency savings that could be re-invested into the service. Whilst it is acknowledged that these rebate schemes could undermine the competition required to drive down the costs of medicines, a number of service providers felt compelled to sign up to these schemes in order to remain viable. Primary care rebate schemes are now a common feature within the UK health system, with a significant number of schemes in operation. PrescQipp (a not-for-profit community interest company set up to help NHS organisations to improve medicines-related care to patients) have created the Pharmaceutical Industry Scheme Governance Review Body (PISGRB) with the sole aim of giving an unbiased view on the available rebate schemes and making a recommendation to commissioners as to whether these schemes can be supported. Are you able to give us an indication of the estimated savings achieved by drug and alcohol providers following the switch from generic buprenorphine/Subutex to Espranor? Paul Concannon, senior vice president of commercial operations at Ethypharm. We estimate that since the start of 2019 we have saved the NHS approximately £14,760,000 across all the UK services that have offered Espranor when compared to the generic drug tariff over that period. Have all drug and alcohol providers switched to Espranor yet? What are the obstacles for some providers who have not switched yet? In your opinion, what would enable them to switch to Espranor? At this stage, based upon prescription data, we believe that approximately 45 per cent of all oral buprenorphine is prescribed as Espranor in the community in England. In the UK prison estate the percentage is 82 per cent. The reasons given by the organisations that have not made the move to Espranor include not wanting to use a branded product, not wanting to enter into a rebate agreement and not wanting to engage with a pharmaceutical company. We also had a number of organisations that were planning to move to Espranor in 2020 but were unable to due to COVID. We’re hoping to capture further real-world evidence of services that have moved to Espranor to show how easy a change it is, and in particular the patient’s positive experience of the product, which we hope will benefit those services not currently using Espranor. What is the role of the commissioner in finding the most cost-effective drug and alcohol treatments? For example, the switch from buprenorphine or Subutex to Espranor? Kevin Malone, public health programme manager, Thurrock. Generally I believe the role of the commissioner is to review the available treatments, evaluate the evidence base and design these into a service specification that has structure but leaves space for change/innovation during the life of the contract. The increased costs for buprenorphine were astronomical and in our case, left the provider carrying the risk due to the terms of our block contract. So we worked together – the provider sought a safe and more cost-effective solution to reduce the financial risk and that had robust medicines management applied, while I sourced additional funding to meet the reduced uplift in costs. This prevented decommissioning elements of the service to afford the increased medicines costs – fundamentally we all want the same outcomes and it was a case of working together during a turbulent period to stabilise service provision and meet the needs of our clients. What was your experience of working with Inclusion during the COVID-19 pandemic in regards to the increased prescribing of buprenorphine? During the pandemic we were constantly updated by and reassured that the provider was managing the ever-changing situation. All prescribed clients were assessed for home treatment and storage, and some were retained for daily pick up. Policies and standard operating procedures were routinely revised and proactively provided to myself, reinforcing the sense of safety and transparency at a time when site visits were not possible. The Long Game In the last of their three-part series on the past, present and future of buprenorphine, Dr Georges Petitjean and Deanne Burch look at the opportunities, and challenges, presented by long-acting Buvidal injections. The long-acting buprenorphine injection Buvidal was introduced in 2019, providing an opportunity to treat patients who would benefit from longer-term and stable dosing. Since its introduction, Buvidal has not yet been fully utilised as a treatment option in many drug treatment services. Despite Buvidal being a welcome additional option within OST prescribing there are perceived difficulties and important considerations with regards to cost, implementation and ensuring equitable access for patients across national drug treatment services. Long-acting injectable buprenorphine clearly has a place but can present financial challenges and complexities in implementation, as well as pose concerns about continuity of prescribing for patients who move to different areas because of inconsistency in prescribing rates. If long acting injectable buprenorphine is going to become a more common treatment option, then the issues which have been outlined need to be addressed. However, the ongoing exploration of how it may work within drug treatment services in the form of pilots is a positive sign towards its uptake in the future. Dr Georges Petitjean is the substance misuse medical lead for Inclusion, part of Midlands Partnership NHS Foundation Trust. Deanne Burch is the hepatitis C elimination coordinator for the NHS Addictions Providers Alliance (NHS APA). ---------- Dr Jan Melichar A conversation with Dr Jan Melichar Jan K Melichar, MD FRCPsych, is an NHS consultant addiction psychiatrist, visiting senior lecturer at Bath University and visiting professor at the University of South Wales. In 2020, he put in a successful bid to the Welsh Government to fund nationwide use of Buvidal. Working together with colleagues, he has rolled it out to more than 1,000 patients and has personally given more than 400 injections to over 100 patients. What were your fears and expectations when you first began prescribing Buvidal? To be honest, I was excited to start it as I saw it as a big step forward for many patients. Having worked at getting the most out of buprenorphine for the past two decades, I knew it would be great for settling the peaks and troughs you see with daily dosing. That understanding had led to me to using daily buprenorphine for outpatient detoxification (‘detox-in-a-box’) and seeing it as valuable in the opioid analgesia dependency (OAD) field. Some OAD patients were on so many short and medium and long-action opioids they were in a constant up and down of opioid effects. So I was very excited about seeing it in action, in terms of smoothing things for people on daily opioids and becoming an amazing detoxification option. What has been your experience as a clinician? Much more amazing and unexpected – life-changing for nearly everyone who is on it. Being on Buvidal did more than just settle the expected daily peaks and troughs – it utterly flattened most people’s cravings and settled their anxieties so they simply moved on with their lives. It was as if the daily grind of heroin/methadone/buprenorphine kept them trapped – it was a daily reminder that they were ‘an addict’ and all their emotional energy each day went to dealing with that. Being on Buvidal freed them from that and released their recovery capital to simply move on. And this was regardless of which opioid they were on at the start. We recently looked at the Kaplan-Meier survival curves for them and found, regardless of sex/age/addiction severity or present drug use – were they on methadone/buprenorphine/heroin/codeine/tramadol before Buvidal? – that four in five benefited. This answers the question, ‘Who is Buvidal for?’ – it’s for everyone. What changes have you seen in your service users? It was, and continues to be, life-changing for most who try it. It suits at least four in five of those who try it – they stay on it, turn up and have used it as the missing link to their recovery. They’ve moved on with their lives. One week after their first injection, they turn up, some having already re-engaged with their families, got back to work, got on with their lives. That persists over the months they are on it. Our fear of bringing out their past traumas – given trauma is the gateway drug, with them self-medicating with heroin and then developing maladaptive coping strategies – have proven unfounded. About half just move on, able to just live their lives again. Of the remainder, about two thirds need to have here-and-now psychological support as past traumas/current issues surface – ably provided by the drug service workers in the coming year as Wales rolls out trauma-focused training for all workers. About 10 per cent need more psychological support. Crucially, though, they have reduced craving, reduced anxiety and therefore have the energy and capacity to engage with that support in a timely way. What has been your experience of implementing Buvidal in your service? We initially thought it would be fantastic for the pandemic – we asked both English and Welsh governments to fund it during that period and the Welsh Government stepped up to the plate – the roll-out across Wales has been fantastic. It’s easiest to summarise in the feedback we get week in and week out – 19 out of 19 nurses we surveyed who had seen it in use wanted to continue using it, the receptionists love it as patients turn up happy, on time and even phone if they’re running late for whatever reason. There was, because of the pandemic, a flexibility in the bureaucracies to support service development at pace. So we implemented fast and developed how we gave Buvidal faster than similar developments in the past – it took years to move out of the shadow of slow-motion starts for oral buprenorphine 20 years ago and we’ve done similar in less than a year. Although there will always be resistance to new things and practices in services, once staff saw the dramatic changes in people they’d long given up on they were equally enthused. What learning would you share with others who are considering prescribing long-acting injectable buprenorphine? Just do it. Get commissioners to fund ten – it can be in the homeless services, primary care, prison releases. Make sure you measure how well they are before starting – quality of life, attendance records, A&E records, engagement with work or family and so on. Measure those again on Buvidal. You should see four in five make improvements, with the majority being significant. Commissioners like engagement figures so note that they attend every injection. Figure out how to run their appointments alongside their injections as there is a risk they will not turn up for appointments outside of that time. Not for the reasons we automatically assume with oral opioids – assuming the worst. instead they miss those appointments as they’re well, getting on with their lives, working, engaging with their families, and don’t need to see anyone. It’s easy to use – a small injection of 0.5ml given subcutaneously. If an old consultant psychiatrist like myself can do it, anyone can. We’ve developed and evolved the practicalities so now we start people on either a weekly dose of 24mg – equivalent to around 16mg of oral – 20-30 minutes after a trial dose of 4mg of oral buprenorphine, so they’ve come in on the usual withdrawal for that, or have a two-day oral buprenorphine dosing of 8mg daily. Then straight to monthly 96mg, also equivalent to around 16mg oral. For the ones that start at weekly 24mg, we then offer a monthly dose the week after of 96mg or 128mg. What are your views on the cost of long-acting injectable buprenorphine? It is roughly £200 more annually than oral buprenorphine so this isn’t actually an issue, especially as Dame Carol Black’s report notes how much, when untreated, opioid users can cost the government per year. Confusion arises as commissioners sometimes forget to include the dispensing and other fees commercial pharmacies get for giving methadone and buprenorphine. Unfortunately, those dispensing fees are sometimes hidden in other budgets or given to commercial pharmacies as a difficult-to-disentangle block grant. So commissioners forget this extra £1,000 that is added to the cost of oral buprenorphine annually and fear the cost of Buvidal as it’s ‘much more expensive’. I don’t think £200 per year more is that much more expensive, do you? How do you see the future of long-acting injectable buprenorphine in services? Massively expanding – we didn’t expect it to be this good, this life changing and this effective. A true game changer which will see services pivot from ‘script and chaos management’ to finally having the capacity to help these people move on from having made the mistake of self-medicating to deal with their childhood traumas and being stuck with that mistake for decades. It’s wonderful to see them suddenly getting back to swimming in the sea of life after so much time simply spent in a daily drowning as they worried about how long they had before they needed their next dose of daily opioid. I suspect we, in the UK, are at the forefront of seeing the changes as we’ve given Buvidal to patients due to the pandemic rather than the select few already stable on oral buprenorphine. I think its remarkable action – the reduction in craving and anxiety and the return of normality – is, in part, due to novel allostatic pharmacology, with us finally seeing kappa antagonism, but that’s another story! Inclusion is running an innovative pilot in partnership with HMP Chelmsford to facilitate a smooth prescribing transition for people being discharged from prison to local drug and alcohol services. We asked Kevin Malone, public health programme manager in Thurrock and commissioner of the local Inclusion drug and alcohol service, for his thoughts on the pilot. What are your hopes for the Buvidal pilot happening across Inclusion Thurrock and HMP Chelmsford? My hopes for the Buvidal pilot are positive. For the right client, can we provide a solution that better meets their needs, mitigates the risk of relapse and breaks the cycle of recidivism? It may not be the solution for everyone, but the broader the range of support available, the more choice we can offer our diverse treatment population. The main legwork with this intervention is ensuring that preparation takes place prior to release, not just for the client but for the range of multi-agency staff that need to play their part in the community, however large or small that role is in supporting the client. I shall have a keen eye on future evaluation data for what is an interesting and exciting opportunity. Dr Georges Petitjean is the substance misuse medical lead for Inclusion, part of Midlands Partnership NHS Foundation Trust: www.inclusion.org Deanne Burch is the hepatitis C elimination coordinator for the NHS Addictions Providers Alliance (NHS APA): www.nhsapa.org The authors have not received any financial or other support from pharmaceutical companies and the articles are their own opinion.