Monday, 11 May 2020

Policy change to address COVID-19

This is the first time I’ve blogged here since COVID-19 really hit. 

If you’re interested in broader reflections on what the crisis might mean for alcohol policy, I’ve written about that for the wonderful Drinking Studies Network here. 

But here I want to identify four specific areas where I think policy change or government guidance could be game-changing for people receiving treatment for issues with substance use.  This doesn’t mean they’re the most important areas of activity or policy at the moment; to be honest keeping on doing the ‘bread and butter’ tasks of substance misuse treatment is the core challenge.  But these are the issues where I think the biggest change could be delivered by relatively simple, almost technical, interventions.  These changes aren’t about the detail of delivering treatment so much as freeing people up to deliver support in the most efficient and effective ways we can manage. 

(1) Buprenorphine and (2) the supervision of medication 
First, I want to talk about buprenorphine.  This is one of basically two drugs recommended to as part of opioid substitution treatment (OST), which means people can avoid withdrawals from heroin (or other opioids) and not have to think about funding their habit, as they’re prescribed medication.  The evidence is strong that these interventions reduce crime and the transmission of blood-borne viruses. 

In normal times, lots of people on OST attend a pharmacy every day to be supervised taking their medication.  This helps ensure that (a) they’re definitely taking it and getting the specified dose; and (b) they’re not having any kind of adverse reaction that means the dose needs tweaking. There’s also a valuable safeguarding role: the pharmacist is seeing them in person and so can see any broader deterioration in health or make a judgement about potential wider issues, such as domestic abuse. 

But there’s a downside to this level of supervision during COVID-19.  Going into town every day increases your risk of catching COVID-19, and the pressure on pharmacies a few weeks ago meant that there were queues as well – at best simply off-putting, and at worse further increasing your risk of contracting the virus. 

So the solution introduced (often well ahead of formal government guidance) was to balance up those risks and ask people to attend pharmacies in person less often than they would normally.  This might increase other risks, of course.  If you’re taking home a whole week’s worth of medication rather than just a day or two, then there’s a greater risk of overdose if you take it all at once, or it could be used as a tool of control by an abusive partner or organised crime group. 

Treatment providers are aware of these risks, and are making decisions on a case-by-case basis, balancing up those risks against those of catching COVID-19, particularly given that lots of people in treatment may already have complicating factors (like hepatitis or COPD) that make them more vulnerable.  And commissioners like me are trying to keep a track on all of this to see if we’ve got the balance right.  (Maybe if pharmacies aren’t so busy, a few of the clients more at risk should have face-to-face contact a bit more often again?) 

One of the other ways we’re managing these risks is to make greater use of buprenorphine, one of the key OST drugs along with methadone.  Generally, in line with national guidance, most people in treatment are prescribed methadone, as it’s cheaper and easier to supervise (drink a liquid rather than dissolve a pill under your tongue), and there’s no any clear evidence buprenorphine delivers better outcomes – in fact, in the early stages methadone seems to keep more people engaged. 

So why use more buprenorphine?  Well it’s less risky if you’re taking it home in larger quantities, as there’s less risk of overdose and less to be gained by using heroin ‘on top’ of your medication. 

And this is exactly what the guidance from Public Heath England, issued a few weeks ago, recommends.  The challenge, though, that buprenorphine is considerably more expensive than methadone, and it costs about seven or eight times as much as it did a couple of years ago.  Some very rough local modelling suggests switching someone from methadone onto buprenorphine costs over £1,000 extra per year.  That might not sound like much till you scale it up: a small shift in a client base of 1,000 (not unusual in large local authorities) will cost £100,000s.  Not easy to find at a time when local authorities are losing large sums every week. 

Of course buprenorphine in its conventional tablet form isn’t the only option; it could part of a range of changes we could make. 

One would be to introduce, as has been done in Wales, ‘depot’ buprenorphine, which works like some long-acting reversible contraception injections: it gives a steady dose of the drug over a week or a month, gradually dissolving – meaning you have stability, certainty, and have to see a nurse or pharmacist less often.  The COVID-19 guidance states local areas could consider this, but resource requirements (amongst other things) will probably make this challenging.  We’re certainly considering this locally, as we have been for a few years (we were hoping for guidance from NICE/PHE this spring, though that’s now clearly not going to happen). 

Another, simpler option, is to introduce delivery of medication, which allows services to still see patients eye-to-eye.  We’re doing this in Dorset and BCP, but at the moment we’re reliant on drivers from other areas of the council, and they don’t have the expertise to offer any kind of clinical judgement as pharmacists might, so we’re both vulnerable to those staff being reallocated, and we need to ensure we’re providing specialist support where necessary.  Both of those will cost money. 

One solution could lie in community pharmacies.  This whole issue of switching people to buprenorphine arises because people aren’t being seen in person so often.  Given that we pay pharmacies for each time they see a client, then surely we’ll have some savings on that ‘supervised consumption’ budget?  Wrong.  In the same section where PHE recommends moving people onto buprenorphine so they don’t have to come into the pharmacy, it also states that local authorities should carry on paying pharmacies their standard amounts for supervised consumption even if they’re no longer doing this as much. 

This makes sense: we don’t want pharmacies to struggle and close, and it’s an accepted principle in the NHS response to COVID-19.  But local authorities aren’t funded like the NHS, and the additional funding being offered by central government is unlikely to meet these costs (if it even makes its way to public health departments). 

So those are my first two asks.  If the government is recommending we keep paying pharmacies while still requiring us to find alternative ways of delivering this kind of supervision, then it needs to find that funding.  And if it thinks generic buprenorphine is a solution, then it would need, again, to find the funding for that. 

I know this might sound like the typical call for ‘more money please’, but these aren’t areas where ‘efficiency’ can solve things on its own.  Buprenorphine and trained staff time simply cost money, and we’re being asked to deliver more of them without being given the means to do so. 

(3) Electronic prescribing 
But if efficiency on its own isn’t the answer, that doesn’t mean we’re not looking at trying to be more efficient.  One of the most surprising things about OST services today is that most of them are still doing their prescribing on paper.  Every one of the, say, 1,000 clients in an area needs a new prescription every fortnight.  This has to be created on an electronic system, printed out, signed by a nurse or doctor, delivered to a pharmacy, stored by the pharmacy and then sent off the NHS Business Services Authority so the pharmacy can claim back funding.  For almost every other medicine all this can be done remotely.  The prescriber creates a prescription on the electronic system, presses send and it appears in the pharmacy on their electronic system.  No printing, no signing in person. 

This sounds inefficient, but in a time of COVID-19 it’s more than that; it’s risky to staff.  The admin staff involved in printing, and the prescribers, all have to share the same office.  Perhaps they can work out a relay system, where people only come in on certain days, but they either have to come in, or the paper (with possible associated infection risk) has to make its way from the printer in the office, to their house, and back out to the pharmacy.  Not practical.  Someone who is self-isolating or shielding, even if they’re currently fit to work from home, can’t. 

There’s been legislation in place since 2015 that means things don’t have to be this way.  Controlled drugs can be prescribed electronically.  The challenge is that this hasn’t been technically applied to ‘instalment’ prescribing.  That is, you can only send through a prescription that involves one interaction between patient and pharmacist, when (in normal times) most of our prescriptions involve people attending more than once a fortnight.  In fact, even in COVID-19 times, most people are still collecting their medication at least weekly – which would mean they’d need a new electronic prescription every time. 

You might think that’s just a technical problem, and still easier than all the paper we use now, but every prescription can of course carry a prescription charge, so if I’m suddenly having to pay every week rather than every fortnight you’ve just doubled my costs as a patient. 

And this isn’t just about the patient; it’s about the pharmacy again.  Often (and particularly in these times) even though they’ll have one ‘prescription’ and they’ll be giving a week’s worth of medication to someone, this won’t simply be as a single bottle of methadone – the safer, easier option is to sub-divide this into seven, pre-measured doses.  And the pharmacist gets paid different amounts, quite rightly, depending on whether they’ve done this pre-measuring or not.  If it’s just one prescription, with no guidance about those ‘instalments’, then they can only be paid the standard amount. 

I’ll repeat that this is a technical, not a legal, problem – and one that can’t be solved by local areas; it’s a national issue, effectively with IT. 

(4) Supplying alcohol 
Finally, and briefly, supplying alcohol.  Suddenly stopping drinking can have serious health risks if you are dependent on alcohol, so the PHE guidance quite rightly notes the risks of people struggling with alcohol supply in a time of COVID-19 if they’re dependent.  If someone is short of funds, or self-isolating, they may struggle to get hold of alcohol, and therefore unintentionally put themselves at risk. 

Local treatment services can of course support people through this process and assess their needs, but it’s not clear from the guidance whether they’re also meant to be helping people get hold of alcohol.  And if they were, there’s a downside: unlike with buprenorphine, for example, there aren’t clear processes and guidance on the ‘prescribing’ and ‘dispensing’ of alcohol.  But PHE hasn’t issued any either; it’s just said people should make sure they continue to drink.  Lots of areas are developing their own protocols, but these are all slightly different, meaning that there is local variation without necessarily any need.  There is much more to say on this, but that’s probably enough for now: I would welcome national guidance on who is best placed to do this, and how. 

So there you have it.  Four policy asks: 
  • Funding for continued payments to pharmacies 
  • Funding for buprenorphine or similar approaches to reduce risk of overdose and COVID-19 
  • Prioritising electronic prescribing for OST 
  • Policies/guidance for providing alcohol to dependent drinkers who can’t access it. 
I’m not saying we can’t do anything on these – in fact we’re working hard to take all of them forward.  But they’re all areas where central government intervention could make all the difference.  I don’t just mean government could make my life easier; I mean government could actively save lives. 

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