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Post-its from Practice
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We must stop talking numbers and develop
a real interest in positive health outcomes,
says
Dr Steve Brinksman
November 2012 |
drinkanddrugsnews
| 17
www.drinkanddrugsnews.com
Suboxone |
Post-its
The picture in other European countries, though, is strikingly different. In
Germany, 81 per cent of opiate substitution prescriptions are for methadone
compared to 19 per cent for Suboxone. In Denmark, the proportions are 82
per cent for methadone and 16 per cent for Suboxone, and within Scotland it
has been estimated that there are around 22,224 drug users being prescribed
methadone compared to what is likely to be only a few thousand being
prescribed Suboxone. Similarly, within England, the vast majority of those
drug users on opiate substitution treatment are being prescribed methadone
rather than Suboxone.
The preponderance of methadone over Suboxone prescribing in some
countries but not others is puzzling and may have more to do with the
relative price of the two drugs than their therapeutic effect. NICE, for
example, has advised that because methadone is the cheaper of the two
drugs it should be the first-line treatment. Similarly, the national clinical
guidelines (‘orange book’) reiterate the view that if both treatments are
equally suitable methadone should be the first choice treatment. Within a
treatment culture focused on enabling drug users to become drug free,
however, there may be a reason for considering the wider use of Suboxone.
In recent research in Scotland, drug users prescribed Suboxone were
substantially more likely to have experienced a drug-free period than were
those prescribed methadone (McKeganey
et al
2012). In this study the
researchers followed two groups of drug users over an eight-month period –
one group had been prescribed methadone and the other Suboxone.
Importantly this was not a randomised controlled trial and the total number
of drug users followed – at 109 – was not large. Nevertheless the findings
from the study research were striking.
The two groups of drug users were similar in terms of their age, gender,
number of days they had been using heroin over the last three months, and
the ages at which they began using heroin and at which their heroin use
became a problem. The groups were also similar in their desire to be helped
and in their mental health. Where the groups differed was in their readiness
for treatment, with the Suboxone group scoring higher than those being
prescribed methadone on this measure.
Despite the multiple similarities between the two groups they differed
markedly in terms of their treatment outcomes. In the case of those drug
users prescribed Suboxone, the mean number of days on which they used
heroin over the last three months fell from 38.6 days at study intake to 8.5
days at the eight-month interview point. In the case of the methadone
patients the reduction was from 37.4 days at intake to 24.1 days at the eight-
month interview point. Whilst both Suboxone and methadone were
associated with a significant reduction in the frequency of heroin use, the
effect size for Suboxone was substantially greater than that for methadone.
Both treatments were similarly effective in enabling drug users’ attempts to
remain drug free (preventing relapse) where the individual had ceased his or
her drug use at the outset of the study.
*****
Within a treatment culture where increasing attention is being directed at
becoming drug free, and where there is mounting concern at the increasing
proportion of drug-related deaths associated in some way with methadone,
Suboxone may come to be prescribed much more widely within the UK even
despite its greater cost, and we may come to see much closer parity between
the two drugs as part of an opiate substitution treatment regime.
The research described in this article was supported by an unrestricted,
unsolicited investigator-initiated request from Reckitt Benckiser who had no
role in study design, data collection, analysis, interpretation of data, writing of
the manuscript, or the decision to submit the manuscript for publication.
Neil McKeganey and Christopher Russell are based at the Centre for Drug
Misuse Research, Glasgow. Lucy Cockayne is consultant psychiatrist in
addictions at Spittal Street Centre, Edinburgh
A referenced version of this article is available on our website,
www.drinkanddrugsnews.com
During October each year we have the annual
SMMGP conference, which this year was in
London. It was our first conference since becoming
a registered charity and as such it was followed by
our first ever AGM.
The day was well attended as always and had a
stimulating line up of speakers and challenging
topics. Taking part in a question and answer final
session with Linda Harris from the RCGP and Pete
Burkinshaw, chaired by Post Its from Practice’s
previous contributor, Chris Ford, it became clear to
me that shared care as we know it must change. To
clarify, I do genuinely believe that a primary care
based treatment system cannot be effective if it entails no more than a GP
signing prescriptions for OST. And whilst I know this is not what happens in most
shared care schemes, to date this is what our contracts have usually paid us for.
We are moving into an era where public health is to be the driving force
behind drug and alcohol commissioning, albeit, I hope, with strong links with
progressive minded and proactive clinical commissioning groups. We must
recognise that those of us in primary care working with drug and alcohol users
need to show the added value of the care we deliver above and beyond the
provision of a prescription. If we are not able to do this – especially in a
landscape of competitive retendering of services – then economies of scale will
dictate that providers consider reducing costs by employing centrally based
doctors rather than the multi-practice approach currently found in many areas.
So not only do we need to loudly proclaim the obvious benefits of primary
care treatment both as provider and users of these services, but also we need to
highlight the less obvious but still tangible benefits that occur as a result of this.
Primary care based treatments offer easy access to locally based
programmes that can be delivered by practitioners with an intimate
understanding of the local community – services that are delivered in a non-
stigmatising setting and that can accommodate the complexity of poly-drug
use in people who often have other co-morbid medical conditions.
The time has come for us to move away from the blunt instrument of a
payment system that is purely based upon the number of patients prescribed for,
and I issue a challenge to both primary care practitioners and more importantly
to commissioners to develop mechanisms that measure the positive health
outcomes achievable in primary care and stop simply counting ‘bums on seats’.
Shared care has contributed dramatically to improving services, something
we can be proud of. It may well now become a historical note in the evolution
of drug services, however I believe in transforming it – we can usher in an era
where primary care is acknowledged as a major provider of evidenced based,
recovery orientated high quality care within an integrated treatment system;
and one that keeps the individual at the centre. It is a place where those
wishing to embrace abstinence, and where those whose recovery ambitions
might entail many years in treatment, can both be supported.
Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP.
www.smmgp.org.uk. He is also the RCGP regional lead in substance misuse for
the West Midlands.