Scottish Drugs Forum
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THE UPDATED draft version of the “Orange Book” Clinical Guidelines for the treatment of drug problems in the UK – currently out for public consultation - reflects the changing landscape of the drug problem since they were first published in 1999.
At 200-plus pages, the document has doubled in size, in clear recognition that the scale of the UK drug problem and the numbers receiving treatment has expanded enormously, and with it the need for policy and practice guidance. A noticeable and welcoming shift in developing the draft Guidelines – from which other policy forums could learn - is the inclusion of service user and carer representatives within the working group overseeing the revision.
Other significant changes include taking account of shifting drug patterns and trends, such as the rise of cocaine use and recognition of the limitations of the prescription pad for this particular drug. There is also positive guidance on drug testing, basically arguing that there is no need to supervise the drug testing of service users unless in exceptional circumstances.
caution
Meanwhile, the Guidelines also acknowledge the role of self-help such as user advocacy, self-help manuals, websites and Cocaine Anonymous. However, progress on this latter point must be tempered with some caution. Self-help cannot become the only option available in Scotland, especially where there is already a lack of specialist stimulant services for those unable to go down the self-help road.
The Guidelines remind us that Scotland has still to catch up with England on retention rates (keeping people in drug treatment) and also in the range of prescribing options we offer beyond methadone, such as buprenorphine with naloxone (Suboxone®).
That is why it is heartening to see the Guidelines comment on alternative, non-licensed treatments such as codeine preparations or slow release oral morphine preparations for those “not held” on methadone.
Yet, despite the evidence base improving, the Orange Book working group points out that many areas of drug treatment evidence are either lacking or that the research/evidence base comes from outside the UK.
The final version of the Guidelines could have a role to play in addressing these gaps by making explicit the prioritised research areas which are needing attention. For example, the recent SDF conference highlighted the “bald” evidence patches when dealing with the very Scottish problem of benzodiazepine use, or even daily, supervised drug dispensing of methadone.
Certainly, it is most welcome to see the draft Guidelines propose a degree of supervision flexibility when it comes to drug dispensing for those compliant patients holding down a job. But, they could articulate more clearly that high-compliance is not just the reserve of those in employment – most drug users seeking help aren’t in paid employment.
Parents bringing up children, as well as those involved in volunteering, returning to education or job-hunting would also reap the benefits of this more flexible approach. Furthermore, the draft Guidelines are suggesting that direct daily supervision of methadone should last for at least three months for most new clients. This must be open to serious question in Scotland where staff and other resources are already so stretched that some clients have to wait up to two years to access treatment.
unquestioned
Since the guidelines were published eight years ago, we have witnessed the widespread rise of daily supervised methadone regimes in large parts of Scotland – partly explained by fear of street leakage linked to drug dealing and preventing drugrelated fatalities.
Yet in 2007, supervised daily dispensing of methadone appears to have become an indefinite - and unquestioned? - form of treatment for a large and heterogeneous population of drug users. Despite the widespread practice of dispensing, we still see rising drug deaths in parts of Scotland. With daily visits to the pharmacy a constant reminder of a person’s “drug identity”, this type of dispensing can hardly be described as flexible or promoting a culture of autonomy for those wanting to move on.
The pressures of balancing childcare with daily pharmacy pick-ups - not to mention human rights themes vis-à-vis treatment offered to other health population groups – should also be taken into account.
Of course it would be naïve and indeed foolish to throw caution to the wind. Supervised daily dispensing has a key role to play in offering a safe, effective and responsible assessment process that establishes opiate tolerance and dependency (a prerequisite before prescribing potent drugs like Methadone) and promoting future stability.
Nevertheless, it seems hardly fair that while there has been much debate on clients being “parked” on methadone, the practice of “parking” clients indefinitely on supervised daily dispensing continues without many questions about its rationale.