letters and Comment
Post-its from PraCtiCe
When enough isn ’ t enough
Controlling cravings is an essential part of treatment , says Dr Steve Brinksman
SEAN AND I GO BACK A LONG WAY . He first started treatment 15 years ago and has had quite a few treatment episodes over the period he has been with us . These tend to follow a pattern ; he starts opioid substitution with methadone , titrates up to about 60mls at which point he stops using heroin .
Then after a variable period of time – usually between four to 12 weeks – he starts to use again , occasionally at first and then more regularly , often missing pick-ups and appointments , before dropping out of treatment for a spell . Sometimes he comes back to us after a few months , sometimes more than a year goes by , and there have been interruptions while he has been in prison .
He has often done quite well in prison , away from his usual environment , and has been released on a moderate dose of methadone a number of times – but then the usual pattern kicks in . At the beginning of this year he told me he was fed up with this recurring sequence of events but not sure how we could change this .
On discussing his previous treatment episodes , he told me that when he started methadone he quite quickly stopped having withdrawal symptoms , and this was the point at which his dose titration stopped . However he would still crave heroin and despite his best intentions his resolve would eventually crack and he would use again ; sometimes sporadically , but always increasing until the point of falling out of treatment .
On exploring this cycle with him , he felt there was constantly a trigger , like having extra money or bumping into the wrong people . Then it occurred to me that his craving might be the main factor , so we discussed increasing his dose beyond merely stopping withdrawal . I explained this didn ’ t mean he would never come off treatment and that long-term abstinence could still be a goal ; however to get to that point he first needed a sustained spell of not using heroin .
He agreed that we should try this and we titrated him over the next few weeks to 90mls of methadone . Nine months on he remains heroin free and is as well as I have ever seen him . I expect that at some point in the future he will want to try and reduce with a view to becoming abstinent . That will be at a time of his choosing , and meanwhile he is enjoying not constantly fighting against craving .
Sean has made me wonder if we often underdose with OST , in that we treat withdrawal symptoms yet leave our patients to deal with cravings . Is simply controlling withdrawal enough ? It is gratifying to see this as an area picked up in the revised Drug Misuse and Dependence : UK Guidelines on Clinical Management (‘ the Orange Book ’) and I now make a point of asking about craving as well as withdrawal symptoms , when assessing dose titrations .
Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP , www . smmgp . org . uk . He is also the RCGP regional lead in substance misuse for the West Midlands .
And breathe … CliniCal eye
Take time for the all-important moments of therapeutic engagement , says Ishbel Straker
I WAS DISCUSSING WITH A CLOSE FRIEND the other day her newly acquired qualification in counselling . We talked about the various approaches and which methods we leaned towards – I ’ ve always been a Berne groupie myself [ the Eric Berne method , based on transactional analysis ].
My friend asked me how I knew so much about counselling and asked if I had completed a course . I explained that as a psychiatric nurse I was trained in all of the above , with the majority of my course spent learning how to therapeutically engage with patients . I came away considering how far removed we have become as nurses from the intentions of our qualification within the addiction field , and wondered where have the majority of us have landed .
As I ’ ve mentioned before , I stumbled into the addictions field at the beginning of my nursing career and the aspect that captivated me most was having the freedom to invest my time and training in clients who were responsive . This remains the best part of working in this field for me , and one which I have made a priority for the nurses I supervise . This has been a welcome change for most , and one that has been embraced by all staff and clients . It feels important to enable nurses to use their learned skill in all areas of their working practice for their own motivation and for the quality of care provided to our clients .
Therapeutic engagement within a key work setting is like breathing for a psychiatric nurse and I have come to realise that when it is taken away , it leaves nurses bereft of their ability to have a positive impact through meaningful interactions .
That is not to say that administering medication , vaccinating clients , providing them with health checks and harm minimisation support is not essential . What I am saying is , as nurses , we should give ourselves and our clients time for a significant interaction , one which we are able to reflect upon , digest and
‘ I came away con sidering how far re - moved we have become as nurses from the inten tions of our qualification .’
follow up . Simply give yourself time to breath .
Ishbel Straker is clinical director for a substance misuse organisation , a registered mental health nurse , independent nurse prescriber ( INP ), and a board member of IntANSA .
14 | drinkanddrugsnews | November 2017 www . drinkanddrugsnews . com