I have been informed that this is on the agenda for the ACMD meeting in October and been asked to give some feedback and thoughts on it. Naturally we can via a CMP BUT what are your thoughts on us being able to do this as IPs? Should we have full access to all CDs or just selected ones eg Methadone, Buprenorphine, Diazepam etc? Do you feel this will give you more clinical freedom with your clients? Are you ready for this as IPs?
All thoughts are gratefully accepted as I would like to put something together by 20/10/2006. Please reply via this discussion or direct to me at graham.parsons@pcs-tr.swest.nhs.uk.
Thanks.

Graham,
Is there any chance I could get involved in this ?
I feel strongly that the CMP's need doing away with. The previous chief nursing officer said it would increase access to medications for patients. Well it has left us now in a position where we need a Doctor to diagnose opiate dependence. I think I can work out for myself that someone is opiate dependent.
It does need to be clear it should be within the prescribers scope of practice and that will be different for everyone. It should be clear that people are not prescribing in isolation.
There also needs good appraisal and supervsion in place.

I agree with all Simon's comments. People should have the option of prescribing CDs under supplementary prescribing if they want to, but if they feel competent to prescribe them independantly, which I would, that should be an option. It is crazy that we now have access to the rest of the BNF as independant prescribers, but not to prescribe CDs in substance misuse which is our area of expertise. I would be happy to give feedback to this consultation also.

Beverley,
Good point and I wonder if it may be good practice for people to only prescribe cd's as a supplementary prescriber for say a year. It would then after this time be a natural progression to independent prescribing.
The first prescriptions I did was quite scary and it's not much of a security blanket having a Doctors agreement.

Having just sent off a cheque to the NMC for the privilege of prescribing, I too feel strongly that having CDs for addiction restricted to CMPs when all the other medicines can be freely prescribed is ridiculous and shows little understanding of where the expertise actually lies. Most nurses in shared care are there because they are experts in that area of practice and have been guiding GPs for years.

Some nurses, like myself, also act as mentors on the RCGP part 2 certificate, whereby they will assess whether a GP has sufficient knowledge and skill to safely prescribe. It is ludicrous that in a clinical setting I should have to agree a CMP with a GP whose competence I may have been assessing the previous day!

CMPs may be a good option, particularly in complex cases, and should be part of a good overall care plan anyway, but to retain them as a statutory requirement can be seen as professionally insulting.

Having said that Jim, what with the major increase in GP training and the massive expansion of workers (including nurses), who are going to be less experienced, within the drugs field; the GP can often be more knowledgeable and expert than the worker these days.

I agree Jim, but the point is that nurses (not 'workers') who have become prescribers are very experienced, have had to demonstrate this in practice and are limited by the NMC to areas in which they are competent. They must be prepared to prove their competency and currency in their field of practice if challenged.
The whole point of non-medical prescribing is to improve the timely availability of prescribed medicines to patients. Having to agree a CMP for those needing drugs to treat addiction, in a field where there are not many prescribers of any kind, does just the opposite and is a major anomaly in non-medical prescribing.
It may be a statement about the client group, who are seen as manipulative and devious, beyond the scope of all but doctors to manage; it may be because doctors have had trouble for decades in managing this need and can't bear the thought of someone doing a better job; it may be the medical establishment hanging on to the last vestige of control on what used to be their exclusive domain; it may be legislators not wanting to be seen to be handing over criminals to a 'soft touch'.
Whatever the rationale for this restriction, it serves no real purpose, and anxieties about competency are addressed generally in the legislation for all other treatment groups.

I totally agree Jim. I was just making a somewhat unrelated point.

I assume the restriction is mostly political with regard to sensitivity around controlled drugs. This has always been the case and was heightened by Shipman.

I knew we wouldn't fall out!

This is all really for Graham's benefit so he can take the views of as many practitioners in the field as possible forward to the ACMD meeting. BTW who are the nurses on the ACMD? And how many nurses are actually prescribing apart from Beverley and Simon?

Very interesting chaps.
I wonder if someone could 'dumb this down' for me a little. I think i have the gist of it but brain is working paticularly slow today. Also i am interested but don't want to get the wrong end of the stick here.
Please assist a less clinical member to understand some of the jargon used, unusually.
cheers and Best
Tony B

To answer my own question (never a good sign) from what I can make out, there are 3 nurses out of the 36 members of the ACMD, two hold academic positions, (one is also a service manager) and a third is a service director. I hope they read this forum too.

Tony,
Good to have you bring it to the real world!
CMP = clinical management plan, to be agreed with doctor, patient and nurse regarding what will be prescribed
IP =Independent Prescriber, who does not need to check with anyone else before prescribing.
NMC = Nursing and Midwifery Council, which regulates those professions
ACMD = Advisory Council on the Misuse of Drugs: a group set up as part of the Misuse of Drugs Act to advise the government on policy.
CD = Controlled Drug
RCGP=- Royal College of General Practitioners

Any other jargon I have missed?

It seems like there are still very few nurses prescribing in this field. Dr Emily Finch, addiction consultant, said she has heard of a unit where nurses are prescribing from a limited formulary of about 12 drugs - don't know any more about that. I wonder if the lack of any extra pay for taking it on after passing a hard course puts people off?

Thats great jim
It was this particular thread that got me a little OJ'd(over or out jargoned)
Now i see where the discussion is going
cheers
Best
Tony B

It's quite funny really.
I know of most of these terms etc but you start putting them all together they become indistiguishable.
From ACMD to CMP to IP by the time CD came along i had lost all will let alone any knowledge previously obtained.
It's not a criticsm as this is a clinical site these things are to be accepted. Tho i would rather be bafled by science than acronyms.
Best
Tony B

Tony,
Boil it all down and what we are saying is that Nurses and Pharmacists prescribing has been controlled in regards of prescribing controlled drugs. The main areas is within substance misuse and we are not happy with it.
The previous chief Nursing officer wanted non-medical prescribing to speed up access to treatment. The clinical management plan makes it dependent on Doctors to diagnose and it doesn't take a Doctor to diagnose Heroin dependency.
I know things will change and things have changed quickly, but it is a bit frustrating sometimes.

Interesting discussion folks. I am obviously an advocate of this and fully support this development. It has been suggested by my course tutor (Bath Uni) in relation to ALL areas of independent prescribing that the "inexperienced" IP could work with CMPs for a period of time e.g. 6-12 months then work without them after this period. Naturally as NMP we will be working as part of a multi-disciplinary team (MDT) and will have this support around us. I do accept that many nurses and pharmacists in this area of practice will have more knowledge and desire to work in this field then many GPs BUT we also know many GPs who have provided a dedicated service for years with great skill and application. Every profession will have a broad church of knowledge and competence and it is this MDT working that makes this field so interesting.

My thoughts are these:
1. We should have the access to all CDs so we can manage our client effectively in a MDT framework.
2. It would be appropriate to work within a CMP for SOME NMPs for a period of time but this should not be part of the requirement as each NMP will have their own competence level. Every client will have a treatment plan and the MDT management will allow good governance.
3. It would be good practice for each NMP IP to have a mentor to discuss their prescribing and development and guide them through the complexities of prescribing and management of clients. Mentors may suggest the period of "initiation" and drugs that the NMPs may prescribe within a supportive framework.
4. IF a list was needed for our area of specialism we would need AS A MINIMUM: Methadone Mixture 1mg/1ml (&SF / tabs for hols??), Buprenorphine tablets (all strengths), diazepam tablets, chlordiazepoxide capsules -(please add others). However, I do not support the introduction of a selective list because it would limit our clinical responses and the safeguards of the MDT is in place.
5. Access to all medications and the development of competent NMP IP will IMHO improve access and quality of service to clients

I will share this discussion with the ACMD member and please continue the discussion so all viewpoints can be explored.
(Simon + any other members-please feel free to contact me by e-mail or on 01752 434870 if you want more detailed input and unified response)
Graham.

this talk of a list (which seems in a sense to be like a lesser version of what we have now) made me think about prescribing drugs for which one needs a home office license. Should NMP IPs (to join in the acronym orgy)be able to apply for these (can they already?). It certainly seems appropriate, especially if it was under the supervision of an addiction specialist with a license(these arrangements already exist for many doctors who don't want or can't get an independent license).

No-we can't apply to prescribe certain CDs and i don't think this should be the case. I believe we should have access to the full range of CDs (obviously not diamorphine/dipipanone/cocaine for the treatment of addiction - current HO licence required) BUT if there had to be a selective list ALL NMPs with the speciality of substance misuse should be able to prescribe them. Local agreement in the MDT / mentor could then be formalised.
GP

Hi Graham

I was specifically taking about diamorphine, dipipanone and cocaine. Obviously in reality we are talking about diamorphine. I was thinking that there isa pretty good case for NMPs to apply for licenses in particular if it is a license that is dependent on supewrvision form an addiction specialist. These sort of arrangements are already in place for clinical assisstants and other secondary care medical prescribers.