6 Prescribing

6.1 This chapter discusses the role of prescribing in contributing to the twin functions of making and maintaining contact with drug misusers and changing their behaviour away from HIV risk practices. Our discussion illustrates the valuable contribution which prescribing can make but emphasises that it is not a panacea. In line with general principles laid down in the Guidelines of Good Clinical Practice', treatment, including prescribing, must be tailored to the individual drug misuser if it is to be as effective as possible in bringing about the desired changes.

Possible Purposes of Prescribing

6.2 In addition to the direct treatment function of assisting withdrawal from drugs, prescribing may serve two wider purposes directly related to our goal of containing the spread of HIV:

a. Attracting more drug misusers to services and keeping them in contact

Available evidence supports the view that a prescribing function in a drug service can be successful in attracting some drug misusers who would otherwise not approach services (or at least not do so until a later date). A recent study found that the vast majority of drug misusers interviewed would prefer a service which offered some form of pharmacological support. Of these, most favoured flexible arrangements rather than fixed options though the next most commonly mentioned option was a reducing prescription. Less than 20 per cent of the total sample (23 per cent of those not in contact with services) considered maintenance the ideal. We have also received anecdotal evidence of individual drug misusers taking drastic steps, such as moving house, to obtain treatment which included a prescription. Set against this, we note that many non-prescribing agencies are successful in attracting clients despite the proximity of a prescribing service. We conclude that prescribing is one of a number of factors which may attract drug misusers to services; for some it may be the most important, for others less important and for some it may be a deterrent. As with other aspects of service provision we consider that a range of approaches is necessary to attract the maximum number of drug misusers.

b. Facilitating change away from HIV risk practices

Research on the effect of prescribing in helping drug misusers towards abstinence is inconclusive. This is perhaps not surprising in view of the heterogeneity of drug misusers and the wide range of prescribing and other interventions which may be used. It is clear however that prescribing has helped some toward abstinence but has not helped, and has sometimes hindered others. But the advent of HIV means we must now address a different question; what role can prescribing play in moving drug misusers away from practices which can spread HIV? Here again there is no empirical research which enables direct comparison of prescribing and non-prescribing interventions and conclusive research may be impossible since drug misusers in either programme would be self, rather than randomly, selected. But there is evidence that the prescription of licit oral drugs to drug misusers is often associated with a reduction in their injecting of illicit drugs. There is also evidence that drug misusers in contact with prescribing agencies are less likely to share injecting equipment, though the role of prescribing in this is unclear. We conclude that prescribing can be a useful tool in helping to change the behaviour of some drug misusers either towards abstinence or towards intermediate goals such as a reduction in injecting or sharing.

Prescribing as a tool in fighting HIV

6.3 Para 5.2 identified the need for all interventions with drug misusers to recognise a hierarchy of goals and to work initially towards whichever goal or goals is most readily achievable. Once these `intermediate' goals have been achieved efforts can focus on higher goals (ultimately abstinence) but great care must be taken with each individual not to prejudice what has already been achieved. For some drug misusers, prescribing will help attract them to treatment and improve the effectiveness of the treatment. In each such case, the purpose of prescribing should be clarified from the outset and the goals to be achieved identified by discussion/exploration with each drug misuser. The treatment given and the goals set should be individually tailored to the needs and circumstances of each drug misuser. In many cases, it will be necessary to identify, and work towards, intermediate goals which fall short of abstinence. Subject to our recommendation below about the levels at which prescribing should take place we recommend that the range of acceptable goals should include:

a. the cessation of sharing of equipment
b. the move from injectable to oral drug use
c. a decrease in drug misuse
d. abstinence.

6.4 Having identified goals and decided upon treatment, it is most important that progress toward (or away from) these goals is monitored. If, over a reasonable time, the treatment being given is not resulting in progress towards the goals set then it must be reviewed and a new plan considered. This may include replacing outpatient prescribing with prescribing in an inpatient/residential setting, increasing involvement of third parties (e.g. family, drug-specialist or generic staff), or perhaps revising the agreed goals if they have been set too high. No treatment package should continue indefinitely without review if it is failing to bring about, or sustain, a desirable change. This applies equally to non-prescribing interventions where review should include consideration of prescribing.

6.5 Where intermediate goals are being achieved the object should be to set higher level goals following further discussion/explanation with the misuser and to monitor progress towards these.
Levels at which Prescribing Should be Undertaken

6.6 We have indicated above that different prescribing responses should be available to help different drug misusers towards a range of goals. In this section we discuss the levels of service at which these responses should be available. There is a clear analogy with other areas of health care: for example, GPs see it as within their remit to prescribe digoxin and propranolol to appropriate patients with heart disease, but require access to secondary level services for second opinions, investigations and the onward referral of more difficult cases.

6.7 In the same way, GPs should be equipped to deal with short-term detoxifications and medium term withdrawal regimes in co-operation where possible with Community Drug Teams or with support from voluntary sector drug agencies. More difficult cases may well require support from, or referral to local District specialist provision including Community Drug Teams and the District psychiatrist with a special responsibility for drug misuse. The most difficult cases, such as those where non-reducing long-term prescriptions or the use of injectables is being considered, or where long-term inpatient treatment is needed, could appropriately be managed at District specialist level but may require referral to Regional Drug Problem Teams. It is important that specialist services should not become `silted up' with cases which can be dealt with at a lower level.

6.8 Accordingly, we recommend that there should be a prescribing element to services in each District and Regional Drug Service which should undertake prescribing along the lines recommended in this report.

6.9 Assessing behaviour and behavioural change will be especially important in cases where prescribing is employed to aid the achievement of intermediate goals which fall short of abstinence (e.g. where the initial goal of treatment is that at para 6.3(a) or (b)). We recommend that wherever possible multi-disciplinary teams should be used in assessing and monitoring behaviour change.

Assessment Procedures for Prescribing

6.10 The need to minimise barriers to drug misusers seeking help and entering treatment is a theme which runs throughout this report. There is evidence of a significant drop-out rate amongst drug misusers who are required to undergo a lengthy assessment process (e.g. 1-2 weeks or longer) before active treatment is commenced. The advent of HIV makes it necessary to `capture' many less well motivated misusers who are more likely still to be deterred by such a process. Equally, the prescribing of controlled drugs, with a high black-market value, in sizeable quantities to patients who have not been thoroughly assessed may exacerbate their drug problem and/or that of others. In turn it may lead to an increase, rather than a decrease, in shared injecting.

6.11 We therefore recommend that different assessment procedures should be introduced dependent on the anticipated treatment including the need for and length of, prescribing. Where prescribing is concerned, a balance must be struck between easy access to appropriate help and proper safeguards. Thus the assessment for a treatment response including time-limited oral methadone prescribing should be substantially shorter than that adopted before commencing longer-term prescribing or the prescribing of injectables. The effect of this recommendation should be to enable many patients to receive initial prescriptions sooner than they do at present.

Prescribing of Injectable Drugs and Non-opiates

6.12 In considering the role prescribing can play in attracting drug misusers to services and in changing behaviour towards a number of goals, it is not necessary or appropriate to discuss the fine detail of every prescribing option. However, it may be useful to explain how two particular types of prescribing fit into the framework we have described. First, prescribing of injectable drugs. Misuse of drugs by injection is particularly dangerous. It carries many risks in addition to that of acquiring and spreading HIV. Even where a drug injector regularly uses sterile equipment he or she may well share equipment on occasions when clean needles and syringes are not immediately to hand. A move from injecting drug use to oral use is therefore very desirable in cases where abstinence is not, for the time being, achievable. Much evidence indicates that such a move is achievable by large numbers of injecting drug misusers. This applies even to those who may have been attracted to clinics because they knew injectable drugs might be available. However, for some drug misusers a move away from injecting will not be achievable at the time they seek help (or consider seeking help). For these individuals the aim will be to:

a. move away from sharing equipment; and
b. provide treatment (in the broadest sense) which may facilitate a gradual change away from injecting use.

Clean equipment and education about safer practices will be required in all cases (see Chapter 5). In some cases, treatment which does not involve a prescription may help facilitate the gradual change from injecting use. In other cases, an oral prescription may facilitate gradual change in itself, may reduce the frequency of injecting drug misuse, and/or may be necessary to ensure the individual's continued participation in treatment thus keeping him/her exposed to therapeutic influence. In some cases — a small minority — prescribing of injectable drugs may be necessary to keep the individual in treatment and/or to ease the change from injecting the drug of dependence to taking a substitute orally. Where this is so, such prescribing of injectables should normally be undertaken for short periods only (rarely more than 3 months). The patient should understand from the outset that a change to oral use will be required, and that the injectable component of the prescription will reduce over time.

6.13 The prescribing of injectable drugs in this way will be an important element in helping some injecting drug misusers to move gradually away from injecting. Such cases will be exceptional. Prescribing injectable drugs carries greater risks than prescribing oral drugs and identifying and managing those cases in which it is necessary is a difficult and specialised task. Considerable safeguards will be required before such prescribing is undertaken and progress will need to be monitored very carefully. We therefore recommend that cases in which prescribing of injectable drugs is being considered should be managed by, or with guidance from, the District or Regional specialist team.

6.14 It has been argued that open-ended prescribing of injectable drugs could help to keep individuals who continue to inject drugs away from sharing equipment; so doing would keep the individual concerned in contact with a source of face-to-face health education and would reduce his/her need for contact with the black market (and perhaps with other injecting drug misusers).

However there are strong arguments against such an approach succeeding for the majority of drug misusers and wider practical arguments against such a policy:

—    first, among the minority who may initially need to receive injectable drugs, most can be weaned on to oral substitutes within a reasonably short time;
—    second, there is considerable evidence to show that a high proportion of drug misusers who receive prescribed injectable drugs continue to inject other drugs. These often include drugs which are not designed for injection and this can lead to greater physical damage and serious health problems;
—    third, the long-term provision of injectable drugs may compound an individual's drug addiction, confirm his or her self-perception as a drug addict, thereby reinforcing a sense of hopelessness, and increase his or her drug tolerance;
—    fourth, there is a potential risk of leakage into the black market of drugs with a high street value;
—    fifth, individuals receiving injectable drugs need to be seen more frequently and may therefore rapidly silt up clinics, reducing or removing the clinics' ability to take on new clients.

6.15 In the light of these arguments we recommend that only in the most exceptional case would long-term prescribing of injectable drugs be both necessary and effective in combating the spread of HIV. Any such cases should be managed by, or with guidance from, the Regional Drug Problem Team.

6.16 Finally we turn to the issue of prescribing for misusers of drugs other than opioids. In principle, the considerations discussed earlier in this chapter apply equally to such cases. There are however particular problems and risks associated with prescribing in these cases. Many misusers of amphetamines and other non-opioids are not heavy regular users and there is a serious danger that prescribing for them will increase their drug use leading in turn to greater instability. There is also a particular problem with prescribing drugs in tablet or capsule form which may subsequently be injected causing serious harm. We recommend that in general, publicity and outreach combined with syringe exchange and advice and counselling services are the best means of reaching and influencing the behaviour of non-opioid misusers. There may however be very exceptional cases in which short-term prescribing of non-opioids might be helpful.

' Guidelines of Good Clinical Practice in the Treatment of Drug Misuse: Report of the Medical Working Group on Drug Dependence (DHSS, 1984).