28th and 29th of April, 2005-05-09
Why did I go?
The RCGP conference is a high quality national event which allows me the opportunity to get a better understanding of national trends in primary care management of people with problematic substance use. In addition I have the opportunity to meet people working in this field and have one to one discussions.
What new knowledge did I acquire?
I attended 4 group work sessions that were really useful.
1) Laura Sheard, Nat Wright and Charlotte Tompkins presented on their work with detoxification. Their pragmatic randomised controlled trial compared 2 week community based detoxification from a primary care setting using dihydrocodeine versus buprenorphine. 60 people were recruited. 8 people were negative for morphine at the end of the 2 weeks, 7 of them in the buprenorphine group – this was not statistically significant. 23% of the survey group were abstinent at 3 months post treatment.
2) Judith Yates led a session on “Managing the needs of older users”. This session echoed some of the content covered in the “Managing Pain….…” seminar. It drew attention to the need to consider older drug users in our plans for treatment services as their needs are distinctly different from younger people. In particular they are more likely to present with other medical problems in addition (or as a consequence of) their substance use. By the time they are in their 60’s many people on long term methadone maintenance have no intention of stopping their treatment. What are the implications of this? Should we have separate “older people’s” sessions? What plans do we need to make for residential care of elderly drug users? Admittedly there were more questions than answers generated by this group but it did open up a new area of thoughts for me on this subject as I have a small number of people in treatment aged >50 years.
3) In the same session Roy Robertson presented work from Edinburgh which looked at a trial of methadone versus dihydrocodeine for maintenance. As a pilot they examined whether patients could identify which treatment they were taking and demonstrated that they could! Their subsequent trial was therefore “open label”. There was no difference in any outcome measures at 36 months, dihydrocodeine was slightly better for retention in treatment at 6 months.
4) “Managing pain in opiate dependence” was lead by Mark Gabbay. Case studies were used to demonstrate a number of points. The summary information that I took away was:
a) Where patients are being admitted for treatment, consider negotiation with the pain team. Below the waist surgical interventions might be managed with spinal/epidural anaesthesia.
b) Methadone’s analgesic effects are relatively short lived – 4-8 hours, therefore consider co-prescribing short acting narcotic analgesics where necessary. Some delegates considered oxycodone to be a useful adjunct to methadone maintenance in the treatment of pain. Apparently it has an affinity for kappa receptors, whereas methadone is mainly a mu receptor agonist.
c) Use pain scales to tailor treatment to the patient.
d) In dihydrocodeine dependence consider the use of dihydrocodeine reduction programmes.
Full Hall Sessions
Bob Newman from “The International Center for Advancement of Addiction Treatment Baron Edmond de Rothschild Chemical Dependency Institute of Beth Israel Medical Center” spoke on the rights of drug dependent persons to treatment access and choice of provider, and the right to be cared for under the same conditions as apply to the management of all other chronic medical conditions. This much I took as a given, what surprised me was his comments about treatment facilities in the U.S. which seem to be punitive, secondary sector and inaccessible. Bob told us that the predominant philosophy on treatment remained a “Just Say No” legacy of the Reagan era.
Jez Thompson did some “blue sky thinking” leading to discussion of the future for drugs and drug services. Points of note include the developing role of the expert patient, the increase in coercive treatments, our expectations that all doctors in the future will be better educated about drug problems, we might have immunisations against some drug problems, injectable treatments – what does the future hold, we need to consider the children of drug users and what the future holds for them, we need to consider the long term future of our “die hard” opiate users.
Consensus Statement from the Conference
- We recognise the importance of meaningful user engagement in the commissioning of drug treatment service, and call for secure funding and structures to fund this.
- We welcome the large increase in funding for drug treatment services in recent years but there needs to be urgent review of the evidence base underpinning how services are accessed and delivered to ensure that they optimise health gain for drug users.
- The primary care team needs to work in partnership with all other drug treatment services to assess and address the problems of individual drug users within a holistic framework.
Was this helpful to my working role? Was the information gained in line with my current practice? Do I need to change my practice? Do I need to disseminate this information to other members of my team?
Yes, as usual the conference was thought provoking. I need to consider the older drug users in our local services and look at their needs. People with ongoing needs such as chronic pain or an acute need for pain relief need better support – I hope that our hospital liaison nurse helps us meet these needs. I need to continue to scan the horizons for new developments in this field.
I was reassured that there was still no good evidence to support using dihydrocodeine in detoxification. Its use in maintenance is more promising but the systems, such as supervised consumption, that we have in place to safeguard our service users and their families do not currently lend themselves to dihydrocodeine prescribing.
My current practice will not change a great deal but I need to think about the differing needs of older people and those people who have acute or chronic pain in addition to their drug dependence needs.
To disseminate the information I will forward this to Lifeline team leaders and present some of this information to our local shared care forum.
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