Danny Mogford , Consultant Psychiatrist, NHS Lothian

02 November, 2020

Standard 2 : All people are supported to make an informed choice on what medication to use for MAT, and the appropriate dose.

Danny Mogford is a Consultant Psychiatrist in West Lothian committed to delivery high quality treatment and choice to people using services in West Lothian.

Long-acting Injectable Buprenorphine: West Lothian’s Experience

Along with our partners, the Community Addictions Service in West Lothian has been working hard to improve our responsiveness to the needs of people with drug dependency, their family, friends and others affected by their problems. A part of this effort has been the availability of on-the-day, short notice and booked appointments in a prescriber clinic on all days that we are open. This service change was implemented with an eye on the anticipated Medication Assisted Treatment Standards in development by the Scottish Drug Deaths Taskforce.

Alongside psychosocial support, opioid substitution therapy as treatment for opioid use disorders is supported by a robust evidence base and long clinical experience. It is one of the most effective interventions we have in reducing drug related deaths. The primary medication optionsare oral methadone or sublingual buprenorphine.

Notwithstanding reactive changes dictated by resource availability during the COVID-19 pandemic, oral treatment with controlled drugs almost invariablyinvolves relatively restrictive prescribing and dispensing practices, often including daily pharmacy attendance and supervised consumption. For a significant portion of people with problem drug use, these practices represent a major barrier to treatment initiation, treatment retention and psychosocial recovery.

Long-acting injectable buprenorphine has the potential to reduce the burden of treatment to a single monthly injection. In West Lothian, the Community Addictions Service has taken advantage of our prescribing clinic capacity to offer this as an option alongside the more established oral treatments.

The first dose of long-acting injectable buprenorphine was administered by our service in March 2020. To date, this has been the treatment of choice for more than seventy patients (about fifteen percent of our caseload).The expansion in our numbers has been drivenby patient choice.In the eight months since that first patient, more than eighty-five percent of people initiated on long-acting injectable buprenorphine have been retained in treatment.This is a clear indication that we are offering something that is valued by our patients.

Our experience challenges the truism that people in treatment for drug problems don’t like the clarity of mind that comes from taking buprenorphine, preferring thesedation of methadone. Where treatment comes with fewer daily barriers, many are willing to approach the availability of something newwith an open mind. Patients have told us about the positive experience ofmaking important decisions with a clear head. They have talked to us about getting on with life without having to think about their treatment.In contrast to early experiences elsewhere, the people who have been the most vocally positive about, and benefited from, their treatment with long-acting injectable buprenorphine have been those people our service has previously found difficult to engage.

There remain unanswered questions about funding. There are clear cost implications associated with offering a new treatment with a comparatively high drug cost.These costs will be starkly visible on the prescribing budgets of addictions services. We know that effective treatment reduces costs to acute health services, social care, criminal justice and wider society.Serious thought needs to be given to how theseless visible economic savings and anticipated quality of life outcomes are accounted for in our funding models. Our patients are voting with their choice of treatment and we owe it to them to find ways of making our offering sustainable.

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