MAT in the UK; an antipodean perspective. James Bell May 2016

Transcription

1 MAT in the UK; an antipodean perspective James Bell May 2016

2 Disclaimer This talk is sponsored by Indivior In the last 5 years, Dr Bell has received funding for consulting services and presentations on behalf of Indivior, Martindale and Mundipharma. He has received research funding from Reckittbenckiser

3 The good things about NHS Objectively WHO world ranking of health services, NHS ranks 18 th, Australia 32 nd NHS is frugal, costs less than most high-income countries (OECD, 2015) Strong emphasis on EBM and guidelines No cost to patients

4 The good things about NHS for Addictions Prompt access to free treatment All Addictions patients have regular and frequent scheduled keywork sessions and reviews Nationally-mandated systematic monitoring of outcomes with TOP National targets in place to ensure prompt access and good retention in treatment Registration with one GP reduces scope for doctor shopping (Some limited UK private practice with diversion to pay dispensing fees (Fountain, 1999))

5 MAT History in UK 1995 no supervision of methadone dosing. High rates of methadone overdose treatment expansion 2000 new guidelines (initially largely ignored - Strang, 2007) 2005 Guidelines now somewhat being followed - 36% of doses supervised. Reduction in methadone-related deaths. 16%of pts on bup Funded trial of supervised heroin injecting clinics

6 UK Trends in Methadone usage, overdose deaths, and crime

7 UK MAT Clinic 2007 Community drug team keyworkers managed patients in primary care as well as those in clinics Prescriptions last 7-14 days. Patients seen weekly or fortnightly by keyworker. TOP completed 3 monthly. Doctors signed prescriptions, but medical review infrequent. (Underservicing, cf Australian overservicing)

8 Supervised Injectable heroin Small clinics (30 patients), 2X daily attendance for injecting heroin Co-prescribed methadone Ritualised treatment with an emphasis on safety monitoring for intoxication pre-dose, attention to hygiene, post-dose monitoring Target patients persisting in heroin use during MAT

9 Observations on SIH Difficult to recruit patients NOT a honey-pot but excellent retention Highly structured treatment heroin provided enough incentive to retain patients Good suppression of street heroin (but persisting alcohol, cocaine misuse not rare) Supervised, high dose methadone given concomitantly reduced risk of OD

10 Targetsin NHS MAT 1. OST targets retain 75% of new entrants for 3 months 90% of patients have entry, 6 monthly TOP completed Result Excellent retention but was it retention in treatment? - TOP showed >60% long-term patients using heroin - National average methadone dose 56mg/day

11 Changing practice in UK I was funded to a small study on improving MAT outcomes (Bell, 2013) Clinic with 1000 patients, 250 reported injecting heroin >3X per week Most were on 6 days takeaways, average dose 55mg But declined higher doses, declined supervision, and keyworkers supported this because that s what the patients want. There was at times no clear focus of treatment other than retention and regular TOP monitoring

12 UK Addiction Services 2016 Increasingly provided by third sector providers Addictions consultants disappearing Almost all dispensing in pharmacies, clinics have largely disappeared SIH clinics defunded Structured treatment is expensive!

13 How does the NHS shape up against Medicare and the PBS?

14 Prescription opioids UK prescribing figures: Opioid analgesics - increased 32% non-opioid analgesics - increased 11% hypnotics and anxiolytics- increased 4.9% (The Information Centre, NHS; 2007, 2008, 2009, 2010).

15 Prescription opioid deaths UK Cod Dihyd Tramal TOTAL % increase over 9 years, mainly driven by Tramadol (!)

16 Australian opioid consumption Kg Oral morphine Methadone syrup Other opioids Year

17 Morphine and oxycodone prescriptions Australia

18 Overdose presentations to ED AIHW Heroin + opium Prescription opioids Methadone / / / / / / / / /2007

19 Prescription opioids Prescription opioids are a small issue in UK drug services and overdose statistics In Aust, PBS opioid prescriptions increased from 2.4 million in 1992 to 7 million in Oxycodone is now the seventh leading drug prescribed in general practice. Until 2009, heroin was the main drug injected at the Sydney MSIC. Injections of prescription opioids (4000/month) now exceed heroin (1200/month) IDU survey -SROM used by 41%, long-acting oxycodone by 30% -the two products also most likely to be injected

20 Doctor shopping in Australia In , 55,000 individuals identified as prescription shoppers by Medicare Australia Martyres(2004) (Australia) studied 204 fatal overdoses Polydruguse in 90% Prescription drugs in 80% of subjects Decedents accessed medical services 6X frequency of general population, predominantly accessing prescriptions for BZD and opioids

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22 Looking across the channel France massive expansion of treatment from then 53 people in MAT - now ~100,000 patients receive prescription for BPN -~ 20,000 on methadone BPN treatment unstructured Outcomes of expansion dramatic fall in overdose rate But an increase in illicit buprenorphine in neighbouring countries 22

23 Summary In Australia, prescription drugs are a major source of drug-related harm, and our system of health care has contributed to this All Australian doctors who prescribe opioids need grounding in Addiction Medicine

24 Conclusion: responding to the burden of opioid-related disease If addiction services are to have maximal public health benefit, with diminishing resources, we need to focus on mainstream health settings primary care, mental health, hospitals Specialist clinics risk becoming marginalised services for marginalised patients, with a predominant welfare focus

25 Role of primary care Competence to identify and manage opioid dependence, and apply risk management to opioid prescribing, is a priority Although prescribing opioids, Australian GPs are reluctant to become methadone / BPN doctors Stigma appears to be a greater barrier in Australia than in the UK

26 Stigma Increasing stigma around marginalisation resentment of benefits recipients, distrust of the feral underclass, has increased in both UK and Australia. In this context, support for addiction services is tenuous, rewards of working in the field are diminished. In both UK and some Australian jurisdictions, public addiction services are shrinking

27 Drug treatment policy is cyclical MAT policy in US, Canada, and Australia has gone through cycles of increasing regulation, followed by deregulation and expansion, followed by concerns over diversion, and increasing regulation MAT policy in Australia and UK has cycled between orientation to adaptive programs (harm minimization, crime reduction) and change-oriented programs(recovery)

28 UK Recovery - A perception that MAT as being delivered was not treatment - A struggle against the welfare state - A shift in objectives from crime reduction to citizenship - An ideological shift from maintenance to abstinence? - A shift from adaptive to change oriented treatment? - Attitude change?

29 The limits of treatment - Recovery from addiction comes not from medical intervention but from finding of alternative rewards - Recovery does not depend on being off MAT - Being on MAT does not inhibit recovery

30 References AIHW (2008) Australia's health Cat. no. AUS 99. Canberra: AIHW Bell J (1997) Australian trends in opioid prescribing for chronic, non-cancer Pain, Medical Journal of Australia 167; Bell J, Healey C, Kennedy F, Shah A, Faizal M (2013) Evidence and recovery; improving outcomes in opiate substitution treatment British journal of Medical practice 6:1; a601 Fountain J, StrangJ, GossopM, et al (1999) Diversion of prescribed drugs by drug users in treatment: analysis of the UK market and new data from London. Addiction 95; MartyresR, ClodeD and Burns J (2004) Seeking drugs or seeking help? Escalating doctor shopping by young heroin users before fatal overdose. Medical Journal of Australia 162; StrangJ, Manning V, MayetS, Ridge G, Best D, Sheridan J (2007). Does prescribing for opiate addiction change after national guidelines? Methadone and buprenorphine prescribing to opiate addicts by general practitioners and hospital doctors in England Addiction, 102, The Information Centre