When prescribing regimes are preventing service users from moving on, should we be looking at new options? DDN reports \u2018What makes me angry is that they\u2019re treating every drug user as potentially stupid and can\u2019t look after their own welfare, or potentially as a criminal because you\u2019re going to divert your tablets.\u2019 Marcus is talking about the frustrations of being back on supervised consumption. After giving a \u2018clean\u2019 sample at the drug service he was put straight onto a weekly pick-up of 6mg of buprenorphine, \u2018which was brilliant\u2019. But he \u2018started to have a wobble\u2019 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: \u2018I said this is happening, can I increase my dose?\u2019 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. \u2018I accept part of the blame for this \u2013 I should have read the script,\u2019 he says. \u2018But she should have gone through it with me, she didn\u2019t say a word. \u2018I feel as though I\u2019m being punished for using and being honest,\u2019 he says. \u2018She\u2019s saying it\u2019s for my own safety. I said, \u201cI\u2019m a 48-year-old man, I can look after my own safety and I\u2019ve never given anyone any reason to believe I\u2019m diverting tablets\u201d. But no, their policy is, \u201cstart using again and you\u2019re back on supervised until you can give two clean samples\u201d, and that\u2019s it.\u2019 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 \u2018sorting deals out\u2019 at the drug service and the chemist. It\u2019s very hard to get away from. \u2018I\u2019m seeing people all the time \u2013 I know it sounds pathetic, but you only need the tiniest trigger with heroin.\u2019 So what\u2019s going wrong when a highly articulate person feels like they can\u2019t communicate with their drug service? \u2018I don\u2019t know whether they have hard and fast rules or guidelines, but if they\u2019re rules then they\u2019re wrong, and if they\u2019re guidelines they should be flexible,\u2019 says Marcus. \u2018I don\u2019t feel like I\u2019m invested in my own treatment at all. They are treating me, and that\u2019s it.\u2019 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\u2019s having exactly the opposite effect? Rebecca (not her real name) has been \u2018using a bit\u2019 on top of her script, but she can\u2019t tell her drug service the truth about this because they\u2019ll put her back on supervised consumption \u2013 and if this happens, she\u2019ll lose her job and her family\u2019s only source of income. \u2018They\u2019re putting you in a position where you can\u2019t work,\u2019 she says. \u2018I\u2019ve had people say to me in services, when I\u2019ve gone in for treatment, \u201cyou need to think what your priorities are\u201d. I\u2019ve said I can\u2019t come to a group every morning, I work full-time. My priorities? Well, a roof over my head to be perfectly honest with you. \u2018So you\u2019re pushed out of treatment from day one. It makes life doubly difficult. They don\u2019t expect you to be working and they make very few concessions for you.\u2019 It was these issues among their own service users that made WDP look at flexible dosing regimes \u2013 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 \u2013 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 \u2018extended-release injections would seem to have their greatest potential among less stable patients \u2013 those unlikely to take daily doses and perhaps even less likely to regularly attend a pharmacy or clinic for consumption to be supervised.\u2019 They also quote Professor Sir John Strang\u2019s comments that this could be a \u2018game-changer\u2019 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 \u2018who wanted to avoid thinking about drugs and drug-using associates, wished to evade the stigma of substance use, and desired \u201cnormality\u201d and \u201crecovery\u201d.\u2019 Dr Arun Dhandayudham, WDP\u2019s joint CEO and medical director, and Tohel Ahmed, service manager of R3, WDP\u2019s 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. \u2018Stigma is something our service users experience every day, from themselves and others,\u2019 says Dr Della Santhakumar, clinical lead at R3. \u2018This 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.\u2019 The research goes on. WDP\u2019s Innovation and Research Unit is designing a project to evaluate the effectiveness of buprenorphine depots compared to traditional treatment regimens \u2013 but in the meantime the success of the pilot is leading to expansion of the programme to more service users, and across other locations. \u2018This has been a great example of partnership working,\u2019 says Dr Arun Dhandayudham. \u2018It will support good clinical outcomes and give service users greater autonomy to focus on other aspects of their lives.\u2019 How\u2019s it going? Feedback from the pilot\u2019s participants has shown reasons for optimism. But as always, every case is complex and it\u2019s 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 \u2018alright\u2019 and is not tempted to use on top. While she doesn\u2019t 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 \u2018brilliant\u2019. 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\u2019t experienced withdrawals but smoked heroin twice when he had been drinking alcohol. He says he feels \u2018a better person\u2019 for the change of regime. David, aged 43, lives in sheltered housing and was struggling before starting the new dose. Initially he was \u2018not 100 per cent\u2019, but a couple of months on he says he \u2018feels fine\u2019 and is glad not to be tied to the pharmacy every day. Names have been changed to protect identities This article has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way.