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Issue 5 May 2003
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SMMGP
SUBSTANCE MISUSE
MANAGEMENT IN
GENERAL PRACTICE
A national newsletter on substance misuse management in primary care
REDUCTION
NTORS – Choose maintenance or
MAINTENANCE
DETOX
detoxification – not ‘reduction’
The patients who sought treatment in the NTORS methadone Several factors were found to lead to improved
programmes presented with a range of serious and chronic drug outcomes. These included the provision of services
misuse and other problems (Gossop et al., 2000). The most in addition to the administration of methadone.
frequently reported drug problem involved dependence upon The frequency and content of counselling sessions,
heroin, though the majority of patients were multiple drug for example, was found to have both direct and indirect
misusers. After starting methadone treatment, the NTORS results relationships with improved heroin use outcomes. We also found a
showed a range of substantial reductions in problem behaviours. direct inverse relationship between methadone dose and frequency
These were clearly shown in terms of reductions in use of heroin, of heroin use at 1 month follow-up. Although methadone dose was
non-prescribed methadone, and benzodiazepines, reduced injecting not directly related to 6 month heroin use outcomes, its indirect
and sharing of injecting equipment, improvements in psychological influence was reflected through the strong positive association
health, and reductions in crime. between frequency of heroin use at 1 month and at 6 months. This
is consistent with the results from other studies which suggest that
The prescribing of gradually reducing doses of methadone is one of
events occurring very early in treatment can have an effect upon
the most widely used treatments in the UK. NTORS found several
later outcomes. The clients’ perceptions of, and engagement with
differences between methadone maintenance (MMT) and
programmes were found to be related to reduced frequency of
methadone reduction (MRT) programmes. The patients in MRT
heroin use outcomes. An important task of treatment should be to
were more likely to receive low doses and had poorer retention
increase motivation and engagement of patients.
rates (Gossop et al., 2001). Treatment retention has been found to
be one of the most consistent predictors of favourable treatment Two areas in which substance use outcomes gave rise to concern
outcomes. We also found that reduction programmes were involved crack cocaine and alcohol. Although the majority of
frequently not delivered as intended. Whereas the majority (70%) of NTORS patients were primarily dependent upon heroin, a
the patients allocated to maintenance on an intention-to-treat basis substantial minority (about one third) were also using crack at
received methadone maintenance, only about a third (36%) of the intake. In the NTORS sample, although there were increases both in
patients allocated to MRT received reduction. Many patients who the rates of abstinence from crack and reductions in the frequency
failed to receive MRT as intended appeared to have received some of use between intake and 1 year, these improvements appeared to
form of maintenance (Gossop et al., 2001). The failure of almost gradually dissipate over time. For example, by the time of the final
two thirds of the MRT patients to receive reduction treatment as (4-5 year) follow-up, the overall rates for crack use and the
intended raises a number of questions for treatment providers and frequency of use had returned to about intake levels among the
policy makers. If most of the patients for whom MRT is planned methadone patients. This result disguises different patterns of crack
and started, subsequently have this treatment changed, this calls use among those who were using crack and those who were not
into question the appropriateness of either the initial treatment using crack during the period prior to intake. Among those who
planning process or the treatment delivery process, or both. More were using crack at intake, levels of use were more than halved at
troubling was the finding that where MRT was delivered as all follow-up points. In contrast, among those who were not using
intended, it was associated with worse outcomes. crack at intake, there was a gradual increase in the use of this drug.
For this reason, our results regarding use of crack cocaine should be
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interpreted not as indicating a tendency to relapse to pre-admission
patterns among those who were already using this drug at intake,
IN THIS ISSUE
but as being largely driven by the initiation of crack use among
Consultation and user representation -
those who were not using crack at intake.
designing services users want 2
RCGP Guidance for the use of buprenorphine in primary care 3
For alcohol consumption, the outcomes were not satisfactory. At
intake, a substantial minority of the methadone patients were
Viewpoint – Should GPs be involved in criminal justice work? 4
drinking excessively. No change was found at any point during the
What makes for good pharmacy involvement 5
follow-up period. Alcohol is an important but neglected component
Classics revisited – The British System, Strang & Gossop 5 within of the substance use problems of drug misusers in treatment
Paper review - Abstinence, lapse or relapse to heroin use
services. Chronic alcohol abuse is an important cause of medical
after residential treatment and General practice management
complications among drug misusers, and alcohol use is linked to
of illicit drug users in Scotland 6 increased risk of overdose and mortality (Gossop et al., 2002). The
Dr Fixit – Alcohol detox and buprenorphine for detox 6/7
poor drinking outcomes among the methadone patients is a matter
Bulletin board - conferences, publications and information 8
which requires urgent attention by methadone treatment services.
Hot topic - RCGP Regional Clinical GP Leads
Professor Michael Gossop, National Addiction Centre,
and new guidance for GPwSIs 8 The Maudsley/Institute of Psychiatry, London SE5 8AF.
www.smmgp.co.uk
See article and full references at www.smmgp.co.uk
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