SCRA Dependency: the learned helplessness in treatment services

As those who have participated in the KFx NPS training course over the past couple of years will know, the course spends some time looking at responses to Synthetic Cannabinoid Receptor Agonists (SCRAs, Spice, Mamba.) 

For several months before the Psychoactive Substance Act came in to force there was an urgent need to plan for what could happen once the PSA was enacted. 

The course stressed that there would be dumping of residual stocks, as on-line suppliers and head-shops got rid of prohibited stock and, as had happened with ever NPS before it, it ended up sold via the street market.

The course also stressed that agencies needed to prepare for what could happen yet. There was an urgent need to get treatment protocols and pathways in place so that those who had become dependent on SCRAs could access treatment. Agencies needed to start this process before SCRAs were banned. The development of care pathways and proactively engaging with dependent SCRA users was an essential measure and given the looming enactment of the PSA, a time-limited one.

The risk of not acting ahead of the prohibition was that dependent users, unable to access appropriate treatment, would self-medicate using other substances. All too predictably, this has started to happen in a number of areas. Numerous participants on training courses across the UK have recounted cases of dependent SCRA users drifting to heroin or other opiates to stave off their opiate-esque withdrawal symptoms. The same trend was picked up by Max Daly writing for Vice.

Concerned about the lack of tools and resources for working with SCRA dependency, the existing Cannabis Dependency Toolkit on the KFx website was adapted to reflect SCRA dependency. The SCRA Dependency Toolkit has proved popular with a number of workers to prompt discussion about SCRAs and start the process of addressing dependency and promoting change.

The area that still needed to be addressed was how to respond effectively to physical dependency, specially where pharmacological interventions were indicated.

The only significant report on the management and treatment of SCRAs was produced by Project Neptune and the section on SCRAs republished separately in 2016.
The report has very little concrete information on treatment of withdrawal symptoms, saying only:
“No  specific  medications  are  indicated  for  SCRA  harmful  use  or  dependence  and  no substitute prescribing is currently available. Symptomatic management of withdrawal symptoms may be indicated in some cases.”

In the absence of clear direction, piecemeal resources have emerged but haven’t been evaluated, reviewed or been shared with wider audiences. Medical responses have included Buscopan or phenothiazine for nausea. However misuse of Buscopan in custodial settings has increased wariness of using antihistamines in such settings and measures such as peppermint oil have been trialed.

At least one prison treatment prescriber used their initiative and used Pregabalin with some success, until told by senior management not to continue as the medicine was not licensed for this purpose. In other settings, benzodiazepines (such as chlordiazepoxide) have been used.

In a contemporary drugs field where centralized agencies work slowly to national protocols and “evidence-based treatments” can take an age to emerge, we have been left with too little concrete on offer. 

When resources like the BMJ's infograph on NPS don’t even make mention of physical withdrawal symptoms, it can hardly be a surprise that GPs and treatment workers may miss the link between presenting symptoms to SCRA withdrawal and prescribe accordingly.

This ongoing void is increasingly dangerous. Some drugs agencies have stated (both publicly and to dependent users) that it would be easier to work with them if they were using heroin as there would then be a clear treatment protocol. Given such messages from helping agencies, it can hardly be surprising that dependent, unsupported users have done just that.

Following numerous courses in Kent and elsewhere, and after discussion with a number of agencies, there was a clear need for an additional resource to complement the SCRA Dependency Toolkit. The initial idea was for a Severity of Withdrawal index. This would follow on from the dependency toolkit: for those identified as having a physical or psychological dependency, a more detailed exploration of their symptoms could take place. The second stage of this would be a tiered collection of interventions ranging from holistic to inpatient treatment, with potential pharmacological interventions for different presenting symptoms.

On the back of one such discussion, as the tool was being discussed, participants on courses were discussing potential treatments. One we kept coming back to was Mirtazapine. It seemed that it had the potential to address several key issues including craving, sleep disruption, nausea, appetite loss, anxiety and neural pain. It also had an advantage of being less prone to and risky from a misuse point of view, especially when compared to Pregabalin which also could be useful in managing several of the symptoms of SCRA withdrawal.

The Index and Treatment suggestions are very much at a draft stage. What is urgently required is that clinicians stop waiting for some authoritative national guidance on SCRA treatment. Using the guidance from Neptune, the only clinical guidance is “symptomatic management of withdrawal symptoms may be indicated in some cases.” This should be used as the rationale and argument for trialing appropriate pharmacological interventions.

 In turn where measures have been successful (or not) they need to be written up, even if it is only as a brief letter to medical journals. Then and only then will the published evidence base start to emerge. It requires agencies to take the lead and there should be no need to wait any longer.

The draft SCRA Withdrawal Screening Tool and potential interventions can be downloaded here.
It is in draft form and all feedback and suggestions are gratefully received.

Please look after these drug services!

With the LibCons embarked on a whole scale razing of 'that which went before,' huge swathes of health-care are set to be restructured. Proposals in the White Paper have already been made including proposals to:

• dismantle Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs)
• abolish the National Treatment Agency
• abolish the Health Promotion Agency
• establish a national Public Health Service, with Local Authority planning and delivery under local Directors of Public Health
• Increase the role of GP Consortia in commissioning services.

At this stage, details are scanty. Details, for example, of the structure and role of the Public Health Service are yet to be published, and the NTA business plan, published at the start of October, can't yet reflect changes that have yet to be announced.

This lack of detail hasn't (of course) stopped charities welcoming the changes. Addaction for example endorsed the White Paper on NHS reform straightaway, and likewise endorsed proposals for time-limits on methadone prescribing. Given the profile of Michael Howards wife Sandra Howard on their board of trustees, one must suspect that Chief Exec Simon Antrobus is playing nice to the Conservative top brass.

It will be a while before more details emerge. But a key concern in all this is where services for drug users will end up. And this includes the full spectrum of drug services from education and prevention initiatives for young people and non-users through to substitute prescribing, counselling and residential treatment options. It includes harm reduction interventions like needle exchange and longer term interventions that support the journey from problematic use to recovery for dependent use.

Some aspects of service, such as Needle Exchange, will most likely fall within the remit of the Public Health Service and be delivered via local authorities. One worries that in areas with small budgets and high demand, this will result in an increase in delivery via Pharmacy Needle Exchange as the lowest-cost option. Needle exchange has been over-stretched, underfunded and lacked a coherent set of quality standards. It will be incumbent on the new Public Health Service, in conjunction with bodies such as the National Needle Exchange Forum, to develop minimum standards for Needle Exchange in England and Wales in much the same way that Scottish Needle Exchanges are being reshaped thanks to the Guidelines on Injecting Equipment Provision in Scotland.

It's less clear where non-treatment initiatives, especially education and prevention, will come from. Where will Frank end up for example? Will he be run straight from the Departments of Health and the Home office (as is currently the case) or will he find a new home at the Public Health Service. That is of course if he survives at all. Frank could be culled as well - it would be a suprise if he survived unchanged and unscathed.

But the most vexed question is to where drug treatment services will be located. Will they be something that is commissioned and contracted by GP consortia? Or will they be one of the few aspects of patient care deemed not suitable for this model and an alternative will be developed. Almost certainly, Cameron's Big Society will be expected to play a role. This will certainly be of huge benefit in terms of involving peer support groups, mentoring and mutual aid. But it is of less use when it comes to the vexed issues of prescribing and residential treatment. Prescribing, time limited or otherwise, demands the involvement of Doctors in some capacity and so can't be done by a willing army of volunteers. Not that, on the whole, this army of volunteers would have much to do with prescribing, especially methadone.

We don't know at this stage if the funds for treating drug users (or "Problem Drug Users") and distributed as the "Pooled Treatment Budget" will be retained or not. Let us assume for a moment that such a budget is, for now, retained though possibly subjected to the same cuts being made elsewhere in the budget.

While the budget may be retained, it won't continue to be distributed or spent via PCTs as is currently the case. So where would it go? Would it go directly to GP consortia? This would be as close as one can envisage to actually putting control of the budget in the hands of the actual patient. But as some of this would need to be spent on prescribing (something currently done by GPs) there is something of a conflict of interest here - giving the GP Consortia a budget for drug treatment and then expecting them not to spend a large chunk of it on continuing to dispense methadone.

Or would the money end up being controlled by the new Directors of Public Health. And would the budget for treatment for drugs then end up as a ring-fenced fund within the wider Public Health Service budget. Were this not the case, drugs money would end up being spent on other aspects of Public Health - including prevention, smoking cessation and obesity.

Wherever the money ends up, and whoever controls it, part of the expectation at least on the Government's part, is that payment will be made by results. But this creates something of a dilemma. If as seems likely the money which was previously in the Pooled Treatment Budget is transferred across to the control of the Public Health Service, it would then end up being distributed to local authorities according to need based on the scale of the drug problem in that area. It would then need to be used to pay for drug treatment services of whatever persuasion as is the case now. The only big difference is that in theory the treatment provider would be paid by results - which using the current yardstick being brandished by the Government, would be abstinence and getting a job.

This then seems a far cry from a personal health budget which patients can use to purchase whatever treatment they want, where they want, provided it is evidence based. It will be easy for the motivated, for the "ready to quit" to access treatment - they will be manna for the "payment by result" services. Indeed the development of screening tools and profiling (or segmenting as it's now being called) will make all the difference to the profitability of these services. But for the most vulnerable, those with the most complex needs, the most entrenched habits, the risk is that they are more likely to be written off than before. Because the services that are paid by results don't want people on their books that make them look less than successful. And prescribers won't want to be drawn in to a constant battle to justify (or not, as the case may be) long term prescribing even where it may have been beneficial.

How it would be spent - and how this will be directed - may come from within the Public Health Service. But its ideological basis - that may come from another source. Some will hopefully come from evidence-based research, rather than whatever whimsical notion is currently flavour of the month on a discussion forum. But it may end up coming from just such a quarter, given shape and form by a "Addiction Recovery Board." Such a body was proposed by the Tory "Centre for Social Justice" think-tank, the brain-child of Ian Duncan Smith. So while coordination in the short term will be taken within the new Public Health Service it may well be that within this an Addiction Recovery Board will be formed to supervise and direct how money is spent and shape policy. The ideology of this post will be critical - a rigorous abstentionist in this position would have a huge impact on treatment models.

The next few months will be an interesting time. An awful lot of services are petrified that they will be decomissioned and will be jockying for position to ensure that they don't lose favour at the LibCon court. The vocal neo-abstentionists already have a ready ear in the Conservative party. They are likely to receive only muted complaints from a field that looks set to be swept away.

But these plaudits from the neo-abstentionists and quiescence from the mainstream drugs field should not be taken as a sign that all is well. There is no clear structure and the ideology is still being fought-over. It's early days and the feathers in the wind do not bode well.