Where next for drug treatment services?
A consultant pharmacist for substance misuse wonders whether the political focus on abstinence will be helpful for all drug misusers
The coalition Government has proposed to disband the National Treatment Agency for Substance Misuse, along with other arm’s-length bodies. The NTA’s subsequently published business plan was produced during challenging times brought about by a marked shift of focus by the new Government on drug treatment and the threat that the agency will soon cease to exist (at least in its current form).
This has not been helped by the fact that the Government’s new drug strategy will not be announced until the end of the year (2010), although we have seen some indicators of what it might contain. To be fair to the NTA, it has risen to this challenge, but as a clinician I have found myself reflecting on the potential implications.
There is now an increasing emphasis on rehabilitation and abstinence from all drugs (including methadone and buprenorphine) and a reducing focus on harm reduction. For some patients, this could be a good thing. It has been argued that there are significant numbers of patients “marooned on methadone”, and this change of emphasis could provide the impetus to kick-start the review process and move people towards a drug-free life.
I have some sympathy with this view as long as the patient still has a choice. However, to impose it on the majority carries with it huge risks. “Detox” and “rehab” can work provided patients are supported in after-care. This is extremely expensive and there are limited spaces available. If done badly (or rushed), the risk of overdose — and therefore death — from loss of tolerance is high if a patient relapses.
In my view, the suggestion of time-limited prescribing of opiate substitutes such as methadone carries similar risks. Methadone is a cheap, evidence-based intervention. It is probably one of the most researched drugs in the world — we know a lot about it and we know it works.
I have many patients for whom I prescribe opiate substitutes who are working or are in education, but who still feel they need the medicine to maintain stability in their lives. Many others have reduced or stopped committing crime because of the treatment they are receiving. It would concern me deeply if I was mandated (either directly or via “targets”) to reduce or stop treatment if the patient did not feel ready.
So, where does pharmacy fit into this changing environment? It has been suggested that the function currently provided by the NTA may move to the public health arena. My hope is that the harm reduction focus will be strengthened if this happens — some community pharmacies are already screening for hepatitis C and vaccinating against hepatitis B, and needle exchange has helped to reduce the spread of blood-borne viruses.
Although drug treatment services are politically unpopular in some circles, they provide a critical function, and pharmacists are still there on the front line.
The NTA has also recognised that services need to be developed for some of the people that pharmacists have been aware of for years, namely those who misuse over-the-counter drugs, particularly products containing codeine and dihydrocodeine. I am confident that pharmacy will remain an important part of drug treatment services in the future.
Kevin Ratcliffe is a consultant pharmacist for substance misuse working in Birmingham
Citation: Clinical Pharmacist URI: 11022986
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