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A national newsletter on substance misuse management in primary care NETWORK

guidance9 10 11

on how dually diagnosed patients should be managed.

With blood-borne virus Infections, it is now routine practice to screen and pro-actively manage positive cases either through clear referral pathways or occasionally in-house. Indeed there are even targets on this. To provide a comparable package for CMD, further work needs to be undertaken to strengthen the use of validated screening tools and to utilise these to inform treatment options and monitor outcomes.

Pockets of joint work between addictions and IAPT services exist12

, but these

are by no means ubiquitous and often come with strict inclusion and exclusion criteria. This joint working is clearly to be encouraged but does not necessarily help those with more complex needs, who may benefit most from working with a therapist who is dually trained and experienced in both substance use and mental health treatment13


This philosophy of integration, either of individual treatments or between appropriate services, is at the heart of good management of dual diagnosis14

Dear Dr Fixit, .

It is important that this ethos is not lost in the complex and varied way services are now commissioned, nor that these patients with possibly less likelihood of a successful outcome are overlooked or excluded in any cherry-picking that Payment by Results may engender. Perhaps more than ever the challenge exists to ensure the building blocks are in place (screening, pathways, treatment programmes) to provide equitable and effective care wherever the co-morbid patient presents in the treatment system.

Scott Payne, Psychiatrist, Leeds Community Drug Partnership

9 NICE CG51 (2007) Drug misuse: psychosocial inter- ventions: full guideline

10 NTA / BPS (2010) Psychosocial interventions in drug misuse: a framework and toolkit for implementing NICE- recommended treatment interventions

11 Lingford-Hughes A.R, Welch S, Nutt DJ (2004) Evidence-based guidelines for the pharmacological management of substance misuse, addiction and co- morbidity: recommendations from the British Association for Psychopharmacology, Journal of Psychopharmacology 18(3) 293–335

12 NTA (2011) – personal correspondence

13 Hughes et al, (2006) Closing the Gap: A Capability Framework for Working Effectively with People with Com- bined Mental Health and Substance Use Problems.

14 Department of Health. (2007). Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.

I wonder if I could ask your help with Eddie? He is forty-eight-years old, has been a patient of the practice for several years but only came to see me about his drug problem one year ago. He was using heroin (injecting 1gm a day) and benzodiazepines when he could get them. He drank in binges. He requested a quick detox, which we agreed to only after we gave him all the evidence of different treatments. He didn’t complete the detox and then decided he needed a period of maintenance in order to try again. He managed to do this with psychosocial support but only remained drug-free for 10 days. After this he started using again at increased amounts. He asked to go back on maintenance to which I agreed. He has now titrated up to 80mg methadone but continues to take non- prescribed benzodiazepines and his last 2 urines have been positive for heroin but he refuses increases to his methadone dose. His health has not improved and he is about to be made homeless for non- payment of rent. Care and assessment have refused paying for rehab because they say ‘he is not ready’. Treatment doesn’t seem to be helping Eddie – could you suggest how I should take this forward, especially as our commissioner is demanding more people should get off oral substitute treatment?

Answer provided by Jack Leach, Lead General Practitioner in Substance Misuse, Smithfield Services, Manchester


Dr Fixit on managing patients who are not doing well in treatment

Jack Leach provides advice about managing a patient who does not appear to be progressing in treatment. Ed.

Eddie’s situation is not unusual to that of a substantial minority of clients in drug treatment services. They do not appear to be doing as well as we, and they, would like. Before writing them off as treatment failures who need to be either discharged, detoxified, or prescribed a more radical opiate replacement medication, it is worth asking yourself a number of questions. Against what are you judging their progress? Is this a blip or a trend? We tend to compare a client’s progress against our expectations, the stated goals of the client or perhaps how they were at first presentation, or maybe a combination of all three. But the real comparators are how they would be if they were not in treatment, or how they would be if they were in an alternative treatment programme. Unfortunately, even if we think about this, we can only guess. Eddie could be doing worse if he was not in treatment at all. Assuming changes to his treatment programme could improve things for him, what changes might be helpful for Eddie? I would first:

1. Address his immediate physical and mental health problems; there is anecdotal evidence that promoting and improving the health of people with drug dependence not only reduces their short and long term health implications but also helps them tackle their drug problems.

2. Help him with financial problems; it may help his social situation and enable him to tackle his drug problems. If statutory services are unable to help, various local and national voluntary organisations such as Citizen’s Advice Bureau and Shelter may be of help.

3. Use focused psychological support such as motivational interviewing and international treatment


programme (ITEP) to reduce and change his substance using behaviour.

Eddie seems to have problems from his opiate, benzodiazepine and possibly alcohol use. Should these be tackled together or separately? The problems from them will be accumulative and make treatment less successful and more problematic as these illicit and

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