Heroin Assisted Treatment/Enhanced Drug Treatment Service

Dr Saket Priyadarshi , Dr Charles McMahon ,

09 March, 2021

These are two different but complimentary perspectives on the new service in Glasgow which is delivering heroin assisted treatment to some of the people most at risk of experiencing drug related deaths in the city.

A medical manager:

Dr Saket Priyadarshi is the Associate Medical Director for Alcohol and Drug Recovery Services in Greater Glasgow and Clyde. He is a GP by training and started his addiction career almost 2 decades ago, in the same setting where he helped implement and works in the new Enhanced Drug Treatment Service providing heroin assisted treatment.

Why was heroin assisted treated needed in Glasgow?

Heroin Assisted Treatment (HAT) is an evidence based alternative to conventional Medication Assisted Treatment for people seeking support for street heroin use. Although it has been offered at relatively low threshold and at high capacity in some parts of Europe for decades, it remains a controversial and poorly resourced treatment in the United Kingdom, and was unexplored in Scotland at all…until very recently.

Following an outbreak of HIV in people who inject drugs in Glasgow, a health needs assessment confirmed what many clinicians have known for years- that despite having been treated with methadone and/or buprenorphine (and indeed other evidence based approaches including residential rehabilitation), many continue to use drugs in a highly risky manner. The assessment recommended that we pilot HAT for this “hard edges” population, with the aim of engaging them in a treatment they hadn’t received before, one that may at last result in reduced harms and early steps towards recovery.

One of the barriers to implementing this treatment has been the high cost. However, the evidence is of favourable cost benefit and in our business case we were able to evidence the substantial cost to the health and social care system that our target population already incurred, and the likely benefits to police and wider criminal justice systems.

Implementation of HAT in Glasgow

Although HAT is a legally permissible treatment, the service site needed a license which we received following a visit by UK Home Office officials. We were then granted the first individual prescribers’ licenses issued by the Scottish Government.

Reviewing the international literature, we developed treatment criteria and prescribing guidelines best suited to the characteristics of our target group. This was influenced most by the RIOTT study from England, though pragmatically lowering the threshold from the RCT standards used in the study. Essentially, we have offered the treatment to city centre homeless high risk heroin users who had a record of having tried other treatments, but we would not expect them to be abstinent from other substances such as street benzodiazepines prior to starting HAT.

Recognising the complex needs of the people we were trying to engage, we developed a service specification that was aimed at addressing their broader health and social care needs, creating a multi-disciplinary approach in the new “Enhanced Drug Treatment Service” (EDTS). This service was co-located with key partners- the homeless addiction team, blood borne virus colleagues, homelessness GPs, Housing First Officers, Welfare Rights workers and others.

The final piece of the jigsaw, was to source a stable and appropriate supply of diamorphine. Recognising that there were inherent problems in using the UK product, we were able to negotiate a deal to be supplied a Swiss product used widely for this very purpose.

After decades of discussion about such a service in Scotland, years of developing a case for it in Glasgow and months of intensive implementation planning, the service began recruiting patients in December 2019. And then the real work began.

Early signs are promising

To date we have treated 16 individuals, a number restricted by the Covid pandemic, the impact of which we could say more about- but that would be another blog! The first few weeks were nerve wracking- specially the very first injections and titration to effective doses, often 200mg or more of diamorphine per injection.

Whilst it may have been nerve wracking for all staff, the patients knew what to expect from the drug. It is their daily business after all. What they were clearly more concerned about is how we would treat them- not only as patients, but as individuals with distinct histories, issues and personalities. It was clear from the start, that building trust and therapeutic relationships would be the key to success, and were just as important as a safe environment, aseptic reconstitution techniques and prescribing guidelines.

This hasn’t always been easy because sometimes it is the right thing to do to stop treatment or refuse doses for the patient’s welfare or to insist on certain expectations of behaviour in a tight shared environment or to intervene when relationship dynamics between patients become risky; and many of these decisions are contentious not just from a patient perspective, but also because of difference in opinion between staff. It has been an intense year of learning together.

The EDTS is being evaluated formally over 2 years. What we can report at the moment is that the service has been recruiting some of the people with the most severe problem drug use in the city, as intended. In fact, the baseline characteristics reveal an intake who have longer histories of problem drug use and more complex health and social problems than those recruited into the RIOTT studies. In terms of outcomes, everyone in the service now has a roof over their heads and access to food, has been out of prison for any new charges, is less like to use emergency services. Only one patient has “fallen out” of treatment (despite the service’s best efforts) and many are benefitting from support from other partner services, particularly the BBV team, GPs and Housing First.

A true picture, of course, is not all rosy. The treatment has been discontinued in some patients who were not only failing to improve, but in whom there was no evidence of reduction in risk despite optimal dosing and intensive support. The absence of meaningful near patient testing for street benzodiazepines and gabapentinoid use has meant an over reliance on presentation and accounts of drug use, and although this is fine almost all of the time, the service has on a few occasions had to reverse significant overdoses following injecting diamorphine in patients who, it transpires, had these drugs in their system. Treatment with HAT does not necessarily end occasional dabbling in illicit drugs for people with longstanding habits, ongoing isolation and other challenges in their lives, and trauma histories, particularly women.

On the whole though, the transformation in most patients is profound. People who had not slept under a roof, now have keys to a home. They can afford to buy luxuries such as clothes, haircuts and Christmas presents. There is little culinary ability in our patient cohort, but they can afford to eat. They have wounds dressed, negligible viral (HIV) loads, Hepatitis C clearance and some are engaging with GPs for the first time ever. Most rewarding of all, many seem to have regained some degree of self-respect and dignity. A few have engaged with recovery communities and recovery workers, unimaginable a year ago.

The challenge for HAT now is to increase our capacity when the easing of the Covid pandemic restrictions allow and to demonstrate the impact on patients by the results of the formal evaluation. Following the First Minister’s recent announcement, it may be possible to increase HAT services across more localities in Glasgow sooner than we imagined. For staff and patients alike, HAT is an intense experience, but with the correct planning and a focus on relationships between staff and patients, it can be an important part of the jigsaw in response to the drug crisis in Scotland.

 

A clinician’s view

Dr Charles McMahon is an experienced consultant addiction psychiatrist. Having trained in England where he prescribed injectable opiate treatment, he settled into a long career in Renfrewshire where, like the rest of Scotland, such treatments were not available. In this sense his career came full circle when he took on the challenge of being the responsible doctor for Scotland’s first heroin assisted treatment patients.

Extension of harm reduction…

My own view of harm reduction has been an acceptance that some people will want to continue to use drugs and that interventions we may offer are to support them to use with least possible risk to themselves and potentially others.

There is now no real controversy in regard to supply of clean needles, syringes and other injecting paraphernalia, however we do this in the knowledge that with this clean equipment the drugs injected will include heroin of unknown strength often containing dangerous or potentially lethal microorganisms and other harmful contaminants.

In its most basic sense EDTS could be viewed as an extension of equipment provision providing a supply of pharmaceutical heroin to counter the risks of contamination, unknown purity and in addition the risks associated with funding a heroin habit

Despite the simple logic, I have observed both staff and patients struggle with this concept.  The business of drug clinics traditionally has been to support reduction and cessation of injecting drug use, even when observation of that patient’s recent life experience suggests this is not what they want or is not what they are able to do. Staff will struggle with the thought of facilitating injecting drug use and given we have all been for many years highlighting the overwhelming evidence of risks and dangers of injecting this is not surprising.   We have all had to think carefully about the feelings watching someone inject drugs we have given them induce, particularly on the few occasions they have become over sedated, this invariably being related to concealed consumption of street Valium or other sedatives

What the past year has demonstrated is something I was not expecting, that this most basic harm reduction action of providing clean heroin in addition to the clean equipment has for some launched a remarkable recovery journey in terms of improving health and wellbeing.

…And the start of recovery?

It will be very important to study outcomes with proper scientific rigour, particularly with such a resource intensive treatment and this will be undertaken independently. Clearly treatment within EDTS involves a lot more than a simple supply of pharmaceutical heroin and the mechanisms of supporting change will be interesting to tease out. I am keen, however, to highlight the change for some individuals which has been of a scale that was not expected and I have rarely witnessed in over thirty years of treating heroin dependence. This change is present in individuals with the most long standing and severe addiction histories for whom every aspect of life has been destroyed by drugs.

Several of our patients are now in tenancies after in excess of 30 years of homelessness, they are successfully in treatment for HIV and HepC, they are not offending after years of repeated periods of imprisonment, they have had minimal use of acute NHS services including A&E and acute admission wards at a time when the NHS is under unprecedented pressure. In terms of drug use they are supported by a supply of pharmaceutical diamorphine with little or for some no use of street drugs.

There is no doubt in my mind that some individuals have and will continue to derive a dramatic life changing benefit and this in itself makes the service worthwhile.

Our challenges will include how to upscale and understand who out of many others with drug dependence will also gain from engagement.

We will also come to understand the extent of reduction in global risk and movement toward a recovery journey for those whose change is less immediate and less striking.