DDN February 2022 February 2022 | Page 11


We asked Dr Aldrin De Souza , a GP with special interest in addiction , about his experience of prescribing OST during the COVID-19 pandemic . risk of infection within a vulnerable population . Many utilised alternate forms of assessment via telemedicine , and were unable to use drug screens to provide objective evidence of opioid dependence . The result was the rapid increase of sublingual / lyophilisate buprenorphine prescribing due to the perception of increased safety upon initiation . The ability to prescribe buprenorphine in this context enabled service users to continue to receive opioid substitution treatment .
TRANSFORMATION Rapid changes in practice came with the initial stages of the pandemic , such as the limitations on face-to-face assessments and relaxed daily supervised consumption arrangements at pharmacies . This period brought mixed reports from clinicians and patients , with many patients self-reporting reduced heroin use and more stability on prescribed opioid substitution treatment , whilst many clinicians spoke of concerns around risks .
The transformation of buprenorphine into different preparations has given an opportunity for drug treatment services to respond effectively to changing and emerging risks to patients , but also to organisations . During the COVID-19 pandemic buprenorphine ’ s safety profile was utilised to ensure the continuity of opiate substitution treatment for patients in what was an anxiety-provoking time for clinicians and organisations alike , and lessening the risks associated with not being on treatment .
2019 saw the introduction of the longacting buprenorphine injection , Buvidal , which has not yet been fully embraced within all drug treatment services nationally . We examine its place in the future of opiate substitution treatment in our third instalment .
Dr Georges Petitjean is the substance misuse medical lead for Inclusion , part of Midlands Partnership NHS Foundation Trust . Deanne Burch is the hepatitis C elimination coordinator for the NHS Addictions Providers Alliance ( NHS APA ). www . inclusion . org / www . nhsapa . org
The authors have not received any financial or other support from pharmaceutical companies and the articles are their own opinion .
THE HALTING OF FACE-TO-FACE CONSULTATIONS in the first lockdown of the COVID pandemic presented a particular challenge on how best to help any new service users . In the absence of the ability to carry out drug screening this process was even more daunting . It involved carefully balancing the risk of prescribing OST in a possibly opiatenaïve individual and the inherent risk of overdose that accompanies that , versus the risk of not prescribing OST and the risk of harm from continued heroin use .
This uncharted territory , with the absence of a drug screen and face-to-face consultation , was unsettling but the recognition was there that we had to adapt to the circumstances , and very careful history taking was even more important than ever . When medication was initiated , buprenorphine was prescribed due to having the lowest risk of overdose in the titration phase . Risk was also reduced further with the benefit of a pharmacist seeing people daily with supervised consumption – robust harm minimisation advice was also given and naloxone kits provided .
Have all drug and alcohol providers switched to Espranor yet ? What are the obstacles for some providers who have not switched yet ? In your opinion , what would enable them to switch to Espranor ?
At this stage , based upon prescription data , we believe that approximately 45 per cent of all oral buprenorphine is prescribed as Espranor in the community in England . In the UK prison estate the percentage is 82 per cent .
The reasons given by the organisations that have not made the move to Espranor include not wanting to use a branded product , not wanting to enter into a rebate agreement and not wanting to engage with a pharmaceutical company . We also had a number of organisations that were planning to move to Espranor in 2020 but were unable to due to COVID . We ’ re hoping to capture further real-world evidence of services
that have moved to Espranor to show how easy a change it is , and in particular the patient ’ s positive experience of the product , which we hope will benefit those services not currently using Espranor .
What is the role of the commissioner in finding the most cost-effective drug and alcohol treatments ? For example , the switch from buprenorphine or Subutex to Espranor ?
Kevin Malone , public health programme manager , Thurrock : Generally I believe the role of the commissioner is to review the available treatments , evaluate the evidence base and design these into a service specification that has structure but leaves space for change / innovation during the life of the contract .
‘ Increased costs for buprenorphine were astronomical and in our case , left the provider carrying the risk due to the terms of our block contract .’
The increased costs for buprenorphine were astronomical and in our case , left the provider carrying the risk due to the terms of our block contract . So we worked together – the provider sought a safe and more cost-effective solution to reduce the financial risk and that had robust medicines management applied , while I sourced additional funding to meet the reduced uplift in costs . This prevented decommissioning
elements of the service to afford the increased medicines costs – fundamentally we all want the same outcomes and it was a case of working together during a turbulent period to stabilise service provision and meet the needs of our clients .
What was your experience of working with Inclusion during the COVID-19 pandemic in regards to the increased prescribing of buprenorphine ?
During the pandemic we were constantly updated by and reassured that the provider was managing the ever-changing situation . All prescribed clients were assessed for home treatment and storage , and some were retained for daily pick up . Policies and standard operating procedures were routinely revised and proactively provided to myself , reinforcing the sense of safety and transparency at a time when site visits were not possible .