Vol. 1 Talking out of my HAT

I just sent the most recent Clinical Update to the good people at Addiction Professionals (formerly known as SMMGP). In that I cover seven recent papers on various substance misuse subjects. I have included the papers I have used at the bottom of this email but you will need to be a member there to get full access to the 3000 word update itself.

Meantime I can offer you some additional content I wrote at the same time.

Back in the day, when it was SMMGP, there was always a companion Policy Update to go alongside the Clinical Update. This month I wrote about two papers that I was going to include in the Clinical Update but, in the end, I decided they weren’t quite clinical enough for Addiction Professionals.

Let’s get into some thoughts around heroin-assisted therapy (HAT).

Talking out of my HAT

Does heroin‐assisted treatment reduce crime? A review of randomized‐controlled trials. Smart R, Reuter P. Addiction. 2021 Available at: https://doi.org/10.1111/add.15601

In this review the authors found that all of the trials of heroin assisted treatment showed significantly reduced criminal activity among the participants. Four of these RCTs found that the difference was greater than the control groups as well. Inevitably, the reductions were in drug-related and property acquisitive offences. Overall, the authors concluded that while heroin-assisted treatment did reduce criminal activity the studies were variable on whether these reductions were really significantly greater than that achieved by oral methadone treatment.

Perceptions of injectable opioid agonist treatment (iOAT) among people who regularly use opioids in Australia: findings from a cross-sectional study in three Australian cities. Nielsen S, Sanfilippo P, Belackova V et al. Addiction. 2020. Available at: https://doi.org/10.1111/add.15297

This was a survey conducted in Sydney, Melbourne and Hobart between December 2017 and March 2018. Participants who were recruited from various treatment and harm reduction services via a snowball sampling strategy were read a description of injectable opioid agonist treatment. This set out the principles of injectable opioid agonist treatment (iOAT), how often they would need to visit clinics, and what it would entail. They were then asked questions about iOAT programmes and whether they would be interested.

They included 344 people and 53% (n=182) thought iOAT would be good treatment option for them. These were more likely to be male, have used heroin in the past month and be regularly injecting. Out of the 182 interested in iOAT it was found 26% (n=48) would meet the commonly used criteria for inclusion in a iOAT programme. Most (64%) were willing to travel 15-60 minutes to get to a clinic and 27% were willing to travel for an hour or more.

Around 1 in 3 who would be eligible for iOAT were not interested citing the problems of daily clinic attendance and lack of flexibility in the treatment.

Comments and thoughts

The idea of iOAT is bubbling up now in the UK with some pilots ongoing and several other services and regions agitating for heroin assisted treatment (HAT). Given the tragedy of drug-related deaths in the UK there is a strong sense that no option should be off the table.

In the UK, drug treatment is still perceived, at least politically, as a criminal justice problem. It’s a shameful position that is still resulting in skewed priorities. The recent ADDER program that is being rolled out is controlled by the Home Office and while any additional funding is greeted with relief in cash-starved services, it is the Minister for Crime and Policing who is claiming ownership. We shouldn’t let that slip too far back in our minds.

It is worth re-visiting the RIOTT study. This was the major UK-based randomised controlled trial for HAT and was published back in 2010 in the Lancet. The people who were selected in the RIOTT study were refractory to oral methadone — they were already in treatment and they were not being scooped up from the street as serial offenders and then put onto HAT. It was a quite specific additional intervention for people who having particularly difficult time in achieving stability on oral methadone. We should keep this firmly in mind.

It is perhaps churlish to gripe about the source of funding for something like HAT — I can fully understand why people would be pragmatic about this. Yet, we just need to be a little bit cautious while the payer is rooted in the criminal justice system. The pressure to reduce crime, driven by the political drivers that still stalk UK substance misuse services, can affect the clinical groups we may wish to target for HAT.

The Nielsen study from Australia highlights some of the experiences of people who may wish to consider treatments such as HAT. It provides useful information on the likely proportions who could be interested. Like many, I want to see clinical interventions like HAT and DCRs — they have a good evidence base but I’m realistic about how many people they can help. I hope we will see them emerging in months and years to come but it is important that they serve the clinical needs of patients rather than those of the Home Office.

Links to check out

  1. Middlesborough and their HAT project were the first to get a Home Office license. I can’t help noticing that the first thing they mention is the reduction in crime… and there are some honest comments about the difficulties of funding. There were, of course, many other benefits as well but the future doesn’t look straightforward.

  2. This emodule on the emergency management of adverse effects of drugs is a collaboration between Drug Science and the Society for the Study of Addiction. It is a 48-page PDF with a ton of details on emergency management. (I’m going to ignore my reservations on whether you can technically call a PDF an emodule.) It is light on practical clinical advice but it is a weighty collection of evidence and statistics, presented in a series of very palatable infographics. Recommended.

  3. 50 years of the Misuse of Drugs Act and Transform are going big on the 50 year anniversary. Here is all you wanted to know about some of the most lamentable legislation to have disgraced the statute books. And they had a word or two about the dire drug-related death stats as well.

More to come…

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Addiction Professionals | Clinical Update August 2021

Visit Addiction Professionals at https://www.addictionprofessionals.org.uk/

Papers covered in August 2021

Subjective symptoms and serum methadone concentrations: what should guide dose adjustments in methadone maintenance treatment? A naturalistic cohort study from Norway. Chalabianloo F, Fadnes LT, Høiseth G, et al. Substance Abuse Treatment, Prevention, and Policy. 2021;16:1-8. Available at https://doi.org/10.1186/s13011-021-00367-w

Interim methadone - Effective but underutilized: A scoping review. McCarty D, Chan B, Bougatsos C, et al. Drug Alcohol Depend. 2021;225:108766. Available at https://doi.org/10.1016/j.drugalcdep.2021.108766

Effect of extended‐release naltrexone on alcohol consumption: a systematic review and meta‐analysis. Murphy CE, Wang RC, Montoy JC, et al. Addiction. 2021. Available at: https://doi.org/10.1111/add.15572

Cognitive impairment and treatment outcomes amongst people attending an alcohol intervention service for those aged 50. Seddon J, Wadd S, Elliott L, Madoc-Jones I. Advances in Dual Diagnosis. 2021;14:58-69. Available at: http://dx.doi.org/10.1108/ADD-02-2021-0003

Treatment of opioid dependence with depot buprenorphine (CAM2038) in custodial settings. Dunlop AJ, White B, Roberts J, et al. Addiction. 2021. Available at https://doi.org/10.1111/add.15627

Non-financial barriers in oral health care: a qualitative study of patients receiving opioid maintenance treatment and professionals’ experiences. Carlsen SL, Isaksen K, Fadnes LT, et al. Subst Abuse Treat Prev Policy. 2021;16:44. https://doi.org/10.1111/add.15297

Accuracy of a single‐lead mobile smartphone electrocardiogram for QT interval measurement in patients undergoing maintenance methadone therapy. Titus‐Lay EN, Jaynes HA, Tomaselli Muensterman E, et al. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2021;41:494-500. Available at: https://doi.org/10.1002/phar.2521