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prescribed drugs interact1 2


. There is


no definitive answer to this. In general in the community I would suggest tackling one at a time, whilst not taking your eyes off the other. Which to tackle first is based on which the client perceives as most problematic combined with our judgment of which is potentially the most dangerous and which we can have most effect on. Usually overall, regular injecting of heroin is more problematic than regular oral benzodiazepine use and excessive drinking and there is an effective medication to combine with psycho-social interventions. So what medication changes might be helpful? One might consider:


1. Increasing his dose of methadone is likely to be helpful. All controlled studies of methadone suggest that methadone’s effectiveness is dose-related1


. However, he is not


keen to do this. It is worthwhile finding out the reasons for him not wanting to increase his dose, check he is taking his current prescribed dose and frankly discuss with him the potential benefits and disadvantages of increasing his dose.


2. An alternative opiate replacement medication. Eddie is currently on too high a dose for conversion to buprenorphine. For intractable injecting drug use, other alternatives include adding or replacing with an injectable opiate medication, such as methadone for injection or diamorphine. There have been a few controlled trials comparing injectable diamorphine to oral methadone in the international literature3


. They have not shown


a clear advantage. A Dutch study indicated that a combination of oral methadone and diamorphine seemed to give some of the most favourable results. If injecting is not so intractable then another oral opioid might be considered


of which the most promising is long acting oral morphine preparations, though this is not currently a licensed use2


.


3. If benzodiazepine use (BZD) is particularly problematic, should you prescribe a replacement such as diazepam? This is highly controversial.


Unfortunately


there is no more than opinion to guide, as research has not shown converting illicit to prescribed benzodiazepines reduces overall benzodiazepine use, reduces problems from BZD use or improves physical and mental health.


The new national drug strategy 2010 Reducing demand, restricting supply and building recovery: supporting people to live a drug free life attributes the ills of poor communities on drug use, in a similar way to the social devastation in USA attributed to cocaine in the 1960s and 70s and calls on community action to reduce this demand. Unfortunately it seems that it is social deprivation and inequalities that encourage problematic drug use and until social conditions are improved it is unlikely that these communities will reduce illegal drug markets and drug use. The strategy describes recovery as a single predictable path to abstinence from both illicit and prescribed opiate drugs. It suggests that abstinence will enable people to become economically active, coming off state benefits. This constructs people dependent on drugs as a homogenous group of welfare recipients who need to be free of all drug use before they can become proper members of society. Problem people rather than people with problems. However, I believe recovery is a complex concept and consists of different paths for different people at different times.


1 Ward J, Mattick R, Hall W (editors) (1998). Methadone maintenance and other opioid replacement therapies. Amsterdam:Harwood Academic Publishers.


2 Department of Health (England) and the devolved ad- ministrations (2007). Drug misuse and dependence: UK guidelines on clinical management. London: Department of Health (England), the Scottish Government, Welsh As- sembly Government and Northern Ireland Executive.


3 Stimson G, Metrebian N (2003). Prescribing heroin: what is the evidence? Findings September 2003. Joseph Rowntree Foundation.


Should Eddie follow this recovery rhetoric and detoxify and live a drug free life? Unfortunately, Eddie seems to have problems doing this. His previous detox attempts have been unsuccessful and even on a methadone maintenance programme he is still not able to completely stop his illicit drug use. If his methadone was reduced rapidly it is difficult to see how he could stop both his illicit and prescribed drug use in his current situation. So how about inpatient detoxification followed by residential rehabilitation? The cost of this treatment will be high, during which he will stay


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on state benefits and it is likely he will have to give up his home. Research suggests that the majority of people completing detoxification and residential rehabilitation treatment will relapse within the year following their discharge4 5 6


, and


that inpatient setting outcomes do not differ greatly from community. All studies of community opiate treatment suggest that longer-term programmes are more effective that short-term programmes in reducing and stopping illicit drug use, promoting health and reducing risk of death1


. Eddie may not feel willing or ready


to come off prescribed drugs and spend months in a residential rehabilitation unit. So the zeal to implement policy by the commissioners should be tempered by what is likely to help Eddie in practice and this will include what Eddie feels would be helpful to him and what he is able to commit himself to.


4 Mattick R, Hall W (1996). Are detoxification pro- grammes effective? Lancet;347:97-100.


5 Gossop M, Marsden J, Stewart D, Rolfe A (1999). Treatment retention and 1 year outcome for residential programmes in England. Drug and alcohol depen- dence;57(2):89-98.


6 Day E, Ison J, Strang J (2005). Inpatient versus other settings for detoxification for opioid dependence. Co- chrane database of systematic reviews 2005, Issue 2. Art


No CD004580. DOI: 1002/14651858. CD004580. Pub2.


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