Is it common practice to reduce an opiate agonist script in response to continued positive samples for cocaine?

Absolutely not!
It makes no sense whatsoever. They are 2 completely different substances. In the spirit of harm reduction and common practice, reducing an opiate script puts the patient in the increased risky situation of needing to use more illicit substances (ie heroin) to maintain some stability, and to potentially drop-out of treatment. The NTA/Clinical Guidelines et al suggest increasing treatment (ie interventions)if clients are struggling with their treatment/care plans. It is fairly common for substance users to use more than one substance.
Are you being serious?

Sorry for my rant-not directed at you. It is dis-heartening to hear that this practice is occuring.

It shouldn't be, although it certainly used to be quite common. Have not heard so much of it recently but I'm sure it still happens.

Hi Reg

You may have seen this excellent review of the literature: http://www.emcdda.europa.eu/attachements.cfm/att_33859_...iterature_review.pdf

On page 20, it notes: "Agonist maintenance treatment is considered the first-line treatment for opioid dependence (van den
Brink and van Ree, 2003). If additional cocaine use hampers the outcome of maintenance treatment, a first measure would be to optimise this treatment. Thus, an important factor determining treatment outcome is the dose of opioid agonist administered."

So agreed, not common practice to reduce.
But not good practice either.

Cheers
Simon

Thanks Guys,

And dont worry I dont take it personal. This case came up yesterday. A guy on Diamorphine amps told that any more cocaine positives would mean a return to methadone. Other reports are of people on MXL moved to methadone for same reason and the threat of reductions of methadone in 10 mg stages for each stimulant positive sample.

And then he will be sent to bed without any supper.

quote:

Originally posted by Regenerate:
Thanks Guys,

And dont worry I dont take it personal. This case came up yesterday. A guy on Diamorphine amps told that any more cocaine positives would mean a return to methadone. Other reports are of people on MXL moved to methadone for same reason and the threat of reductions of methadone in 10 mg stages for each stimulant positive sample.

I haven't worked in a service that prescribes amps. I would imagine that if we did prescribe it, then it would be for someone who had tried Methadone or Buprenorphine and it hadn't worked. It would seem rather odd to return someone to a treatment that failed in the past.

I think this case is not as simple as it seems on the face of it. I don't prescribe diammorphine, but i know that for some who do, they feel they can only justify prescribing such an expensive drug, and one that is injectable (so no ham minimisation gain in terms of ceasing injecting) that cannot usually be supervised, and that is virtually indistinguishable from street heroin on toxicology testiing, if it genuinely brings about gains in terms of other harm minimisation outcomes (eg stopping crack/cocaine use) This should be explained very clearly at the outset, that it is basically being given on a trial basis, and if not producing such gains, will have to be stopped. In my view, an assessment should demonstrate at least some motivation to cease cocaine use prior to prescribing or risk setting patient up to fail, and they should be offered additional support around the cocaine use if they are struggling. Given all this, if the person genuinely doesn't seem to have gained anything from the diamorph + support after a reasonable and predetermined period of time, then transfering back to oral rx is consistent. That needn't mean that's it forever - a second attempt if circumstances change could be an option.

yes it is a bit different from just saying were taking you off your script - changes the scenario somewhat.

I have certainly known, like Susi says, services prescribing diamorphine be very strict about the health gains they want to achieve with it - otherwise a return to oral methadone. This is for reasons of cost, greater scrutiny that diamorphine scripts come under,political sensitivity and worry that if they can't show really good olutcomes then there might be medico legal problems.

However with the new guidelines on diamorphine prescribing new prescriptions are likely to only be given out under very controlled (and even more expensive) circumstances so this may not be such an issue.

Although, if you read the paragraph in the EMCDDA review linked above that straddles pages 20 and 21 you see the implication that it is those very cocaine-using methadone-prescribed patients who might most benefit from a diamorphine prescription.

And of course, diamorphine isn't just injectable. I used to keywork a patient prescribed inhalable diamorphine.

But I recognise that we are dealing with the UK situation and attendant restrictions so I completely take Susi and Jim's points.

Simon

Many thanks to all. I'll keep you posted

Think many of us forget (I know I do) that there is a big 'drug world' out there which still practice punitively e.g Can I point you to page 4 of 'Are contingency management principles being implemented in drug treatment in England? NTA Research briefing 33 2007 which says 'Negative reinforcement sanctions, such as reducing doses of opiate substitutes are less commonly used. However a quarter of respondents said that clients at their clinics might at least be warned about possible discharge, if they provided a number of positive urine samples for cocaine.' This is appalling but does go on - what in this context is the meaning of treatment? Help me with this on a new thread

I have seen a member of family who is addicted to the OTC Nurofen Plus painkiller for over 7/8 years+. She has a lot of physical and psycologal problems and her husband has done everything to get her medical treatment but she is in denial of having a problem her child has also been disturbed by the effect of this problem.

I wonder if you could gently steer her to this forum www.codienefree.me.uk