Survey of the prescribing practice of Addiction Psychiatrists in the UK for Alcohol and Opiates treatment

Mohammed Ashir, Sheriff Orekan

Abstract

To assess the variation in the prescribing practice for the treatment of alcohol and opiate disorders between addiction psychiatrists who work in specialist addiction units (SAU) and those working within general adult psychiatric units (GAU).

Method

 In a postal questionnaire we enquired about : 1) access to inpatient facility, 2) local guidelines, 3) medications for detoxification and  relapse prevention, 4) duration of medication regime and admission, 5) flexibility of detoxification regime and route of vitamin supplements in alcohol detoxification,   6) specialist treatments for opiates addiction, 7) input from multidisciplinary teams .

Alcohol: SAU psychiatrists significantly used more: 1) guidelines ; 2)flexible detoxification ;3) disulfiram 4) group therapy. More GAU psychiatrists preferred chlordiazepoxide to other benzodiazepines.

Opiates addiction:  SAU psychiatrists significantly used more:1)guidelines; 2) buprenorphine;3)methadone followed by lofexidine for outpatients’ detoxification;4)Naltrexone ; 5)supervised methadone and buprenorphine consumption. Other factors examined were not significantly different. The practice of both groups is similar despite the lack of national guidelines. SAU psychiatrists are more diverse and specialised in their approach. This  reflects level of expertise and the service setting.

Background

Alcohol and illicit substance abuse presents multiple social, psychological and physical problems with huge demands on health resources (Department of Health).

Pharmacotherapy is the mainstay in the treatment of alcohol and opiates addiction. It is directed at the stages of detoxification and relapse prevention and could be delivered at both generalist and specialist services (Rastrick et al 1999). Generalist services include primary care, general hospital services (including accident and emergency departments), general psychiatry, social services and probation. Specialist addiction services tackle more complex drug related problems and require extensive staff training . Many addiction services have psychiatrists as their main prescribers. Addiction psychiatrists are specialists on the Royal College register of the faculty of Addiction (Royal College of Psychiatrists, 2002).

Despite the different issues surrounding the pharmacological treatment of illicit substances there has been little guidance published by any expert or authorizing body like NICE . Furthermore at the time of conducting this survey there were no systematic and evidence-based guidelines available in the UK concerning the treatment of alcohol or opiates disorders. However, more recently the British Association for Psychopharmacology ( BAP) has published its recommendation in an evidence –based guidelines(British Journal of Psychopharmacology, 2004) which we will highlight in our discussion.

Method

An anonymous questionnaire was posted to all 105 psychiatrists on the Royal College register of psychiatrists with a special interest in substance misuse.

 The questionnaire was in two parts, one concerning alcohol and one opiates.

The first three questions were identical  and established whether the respondent was based in a specialist addiction unit (SAU) or within a general adult psychiatry unit (GAU), inpatient facility and whether written local guidelines were being used.

Regarding alcohol, subsequent questions were concerned with medication prescribed for detoxification and those for relapse prevention in terms of “never”, “rarely” and “often” prescribed, route of vitamin supplements prescribed during detoxification, duration of inpatients and outpatients’ detoxification and duration of admission for detoxification and whether the regime was flexible.

For opiates treatment we enquired about what medication prescribed for in-patient and outpatients’ detoxification, duration of detoxification, availability of supervised consumption and specialist treatments.

Finally the input from other members of the multi-disciplinary team was determined.

The SPSS 12.1 statistical package was used and specific chi2 tests were performed to compare practice among psychiatrists working in specialist addiction units and those in general psychiatry units. The categories of “rarely” and “never” were combined in the case of alcohol as few responders replied by rarely.

Results

Of the 105 questionnaires sent 61 alcohol questionnaires and 52 opiate questionnaires were returned and analysed (response rate of 58% and 50% respectively).  The response rate between the two groups was different as some psychiatrists worked in one service only.

We will report the results of each questionnaire separately to ensure clarity.

(A) Alcohol dependence

There were 40 Psychiatrists who worked in SAU and 21 in GAU.

1. Inpatient facility and guidelines availability

Of the SAU psychiatrists 34(85%) had inpatient facility compared to 19(90%) of the GAU psychiatrists. More SAU psychiatrists followed guidelines 38(95%) compared to 18 (86%) of the GAU psychiatrists which was statistically significant (Fisher’s exact test chi2=4.796, df =1, p=0.042; O.R= 5.938, CI= 1.041 - 33.853).

    Prescribing for detoxification and relapse prevention

Detoxification

GAU

SAU

Often

Rarely/Never

often

Rarely/ Never

Chlordiazepoxide*

32 (80%)

8(20%)

21(100%)

0(0%)

Diazepam

4(4%)

17(81%)

14(35%)

26(65%)

Lorazepam

0(0%)

21(100%)

0(0%)

40(100%)

Chlormethiazole

1(5%)

20(95%)

1(2.5%)

39(97.5%)

Relapse prevention

       

Acamprosate

15(71.4%)

6(28.6%)

26(65%)

14(35%)

Disulfiram **

5(23.8%)

16(76.2%)

20(50%)

20(50%)


 *p=0.04

** p=0.035    

Table 1

Table (1) outlines the number (and percentage) of medication “often” and “rarely/never” prescribed by SAU and GAU psychiatrists for alcohol detoxification and relapse prevention. GAU psychiatrists significantly used more chlordiazepoxide (Fisher’s exact test chi2=4.834, d.f.=1, p=0.04) while SAU Psychiatrists significantly prescribed more disulfiram (Fisher’s exact test chi2=3.905, d.f.=1, p=0.035).

 

3. Duration of admission, medication regime and flexibility of regime

In the majority of cases admission lasted between 1-2 weeks – 70% of SAU and 83% of GAU. The remaining duration was 2 – 4 weeks. Admission was never longer than 4 weeks. Significantly more  SAU psychiatrists 38 (95%) followed a flexible regime compared to 16 (76%) of GAU psychiatrists  (Fisher’s exact test chi2=4.796, d.f.=1, p=0.042). The inpatients’ detoxification regime lasted 5-7 days in 42% SAU and 29% of GAU, 7 – 10 days in 40% of SAU and 57% of GAU and 10 – 14 days in 26% of SAU and 14% of GAU. Medication was never prescribed for more than 14 days.

 

4. Vitamin supplements

 

Parenteral only

Parenteral followed by oral

Oral only

None

SAU

6(15%)

11(26%)

21(52%)

2(5%)

GAU

1(4.7%)

4(19%)

15(71%)

1(4.7%)

Table  2

Table (2) outlines the route of vitamin supplements prescribed routinely with alcohol detoxification by SAU and GAU psychiatrists expressed as numbers and percentage. The SAU psychiatrists prescribed more vitamin supplements parenterally, however this was not statistically significant.

5. Non -pharmacological input

 

 

SAU

GAU

CPN

34(85%)

16(76%)

SW

29(73%)

12(57%)

OT

19(48%)

7(33%)

Physiotherapy

10((25%)

3(14%)

Group therapy*

30(75%)

6(29%)

Psychology

25(63%)

9(43%)

Day patient

23(58%)

10(48%)

Voluntary agencies

35(88%)

18(86%)

     

*p<0.0001, O.R= 7.500, CI= 2.289 – 24.575

Table 3 

Table (3) outlines the difference in the availability of input from the multidisciplinary team and voluntary agencies between SAU and GAU psychiatrists. SAU psychiatrists significantly accessed  group therapy more than GAU psychiatrists (Fisher’s exact test: chi2=12.273, df.=1, p<0.0001; O.R= 7.500, CI= 2.289 – 24.575).

(B)  Opiates dependence

39 psychiatrists who responded to the opiates questionnaire worked in a specialist addiction unit while 15 worked in a general adult psychiatry unit.

1. Inpatients’ facility and guidelines availability

93% of the GAU psychiatrists had inpatients’ facility compared to 85% of the SAU psychiatrists. More SAU psychiatrists followed guidelines 36(92%) compared to 9 (60%) of the GAU psychiatrists which was statistically significant (chi2=8.142, df =1, p=0.004; O.R= 8.000, CI= 1.670 – 38.323).

 

2.  Prescribing for detoxification and relapse prevention

 

In-patient detoxification

GAU
SAU
 

never

rarely

Often

never

rarely

often

Methadone reduction

5(33.3%)

5(33.3%)

5(33.3%)

8(23%)

12(34%)

15(43%)

Methadone+ lofexidine

7(47%)

5(33%)

3(20%)

9(26%)

12(34%)

14(40%)

Lofexidine only

3(20%)

6(40%)

6(40%)

2(6%)

12(34%)

21(60%)

Buprenorphine reduction*

10(67%)

2(13%)

3(20%)

5(14%)

18(52%)

12(43%)

Codeine

7(47%)

5(33%)

3(20%)

14(40%)

19(54%)

2(6%)

 

never

rarely

often

never

rarely

often

Out-patient detoxification

           

Methadone reduction

3(23%)

2(15%)

8(62%)

2(5%)

13(33%)

24(62%)

Methadone+ Lofexidine**

6(46%)

1(8%)

6(46%)

8(21%)

18(46%)

13(33%)

Lofexidine only

4(31%)

3(23%)

6(46%)

6(15%)

18(46%)

15(39%)

Buprenorphine reduction***

7(54%)

2(15%)

4(31%)

6(15%)

9(23%)

24(62%)

Codeine

4(31%)

7(54%)

2(15%)

14(36%)

22(56%)

3(8%)

* p=0.001

* *p=0.034

*** p=0.021

Table  4

Table (4) outlines the number (and percentage) of medication “often”  “rarely” and “never” prescribed by SAU and GAU psychiatrists for opiates detoxification. SAU psychiatrists significantly used more buprenorphine for inpatients and outpatients’ detoxification than GAU psychiatrists (chi2=14.127, d.f.=2, p=0.001, chi2=7.756,df=2,p=.021). Similarly detoxification by methadone followed by lofexidine for outpatients was significantly used more by SAU psychiatrists (chi2= 6.767,df=2,p=0.034).

 

3. Duration of detoxification

There were no significant differences in the duration of inpatients or outpatients’ detoxification between the two groups. Inpatients’ detoxification lasted two weeks in 60% and 40% and three weeks in 32% and 28% of the cases in SAU and GAU respectively.

Out-patient detoxification lasted more than 4 weeks in 30% of the cases in both groups.

 

4. Specialist’s opiate treatment and supervised consumption

 

 

GAU  

SAU

 

never

rarely

often

never

rarely

often

Methadone maintenance

4(27%)

3(20%)

8(54%)

4(10%)

3(8%)

32(82%)

Injectable methadone

8(53%)

7(47%)

0 (0%)

16(41%)

20(51%)

3(8%)

Buprenorphine maintenance

8(53%)

3(20%)

4(27%)

10(25%)

17(44%)

12(31%)

Naltrexone *

4(27%)

2(13%)

9(60%)

1(3%)

13(33%)

25(64%)

p=0.015

Table  5

Table (5) outlines the specialist treatments for opiate addiction we enquired about. The SAU group prescribed naltrexone significantly more (chi2=8.368,df-2,p=0.015).  Of  the SAU psychiatrists 33(85%) and 29(74%) had  access to supervised consumption of methadone and buprenorphine respectively compared to 9(60%) and 4(27%) of GAU psychiatrists, which was statistically significant (chi2=3.798, df=1, p=0.051, O.R.= 3.667 and chi2=10.368, df =1, p=.001, O.R= 7.975 respectively).

5. Non -pharmacological input

 

SAU

GAU

CPN

34(87%)

12(80%)

SW

28(72%)

11(73%)

OT

13(33%)

5(33%)

Physiotherapy

7((18%)

1(7%)

Group therapy*

27(69%)

8(53%)

Psychology

21(54%)

5(33%)

Day patient

20(51%)

6(40%)

Voluntary agencies

33(85%)

10(67%)

     

Table  6  

Table (6) outlines the availability of input from the multidisciplinary team and voluntary agencies between SAU and GAU psychiatrists. No significant differences were found between the two groups.

Discussion

This survey reveals no major difference in the service provision available for both SAU and GAU psychiatrists when looking at the availability of inpatient facility. However for both alcohol and opiates treatment SAU psychiatrists appear to be more “specialised” in their practice. This is highlighted by more use of guidelines and specialists treatments like disulfiram for alcohol or naltrexone for opiates. 

In alcohol treatment, both groups preferred benzodiazepine as opposed to chlormethiazole for combating alcohol withdrawal symptoms. This is inline with the current evidence (Williams and Bride 1998, Shaw 1995,) and available guidelines including the more recent BAP guidelines and reflects awareness of the recommendation from the Committee on Safety of Medicines regarding the risk of respiratory arrest if alcohol is drunk when using Chlormethiazole (Committee on Safety of Medicines, 1987). For the purpose of relapse prevention in alcohol both groups preferred licensed medication with more evidence base of efficacy like acamprosate and disulfiram (Geerlings et al 1997, Besson et al 1998  ) More SAU psychiatrists used disulfiram and one could conclude that psychiatrists working within a specialist addiction service are more comfortable in using treatments that require close level of supervision. Similarly more than half of the psychiatrists in both groups relied on oral rather than parenteral thiamine for routine prescription of vitamin replacement. For patients at risk of Wernicke’s encephalopathy the current recommendation is to administer thiamine parenterally due to impairment of oral absorption in malnourished patients (Sgouros  et al 2004). Parenteral administration could carry a risk of anaphylactic shock (Cook 1998); however the BAP guidelines conclude that the risk benefit ratio is in favour of parenteral thiamine.

When considering opiates treatment, methadone appears to remain one of the main drugs used in detoxification despite the availability of other new and effective medications (Gowing et al 2003a,b). SAU psychiatrist were more prepared to use alternatives to methadone. Fore example, while two thirds of both groups used methadone often, two thirds of the SAU psychiatrists also often prescribed buprenorphine compared to only one third of the GAU psychiatrists. Although there was a trend for SAU psychiatrists to prescribe methadone maintenance more, there were no such differences for other controversial specialist treatments like injectable methadone.

 

References

1) Besson  J.  et al (1998). Combined efficacy of acamprosate and disulfiram in the treatment of alcoholism: a controlled study. Alcoholism: Clinical and Experimental Research; 22: 573–579.

2) British Association of Psychopharmacology (2004). Journal of Psychopharmacology;18: 293-335.

 3) Committee on Safety of Medicines  (1987).

4) Cook C (1998).  Vitamin B deficiency and neuropsychiatric syndromes in alcohol misuse. Alcohol Alcohol;  33:317-336.

5) Geerlings et al (1997). Acamprosate and prevention of relapse in alcoholics. Results of a randomised, placebo controlled, double blind study in out-patient alcoholics in Netherlands, Belgium and Luxembourg. European Addiction Research;3: 129-137.

 6) Gowing et al (2003a). Burenorphine for the management of opioid withdrawal (Cochrane review) .In: the Cochrane library. John Wiley & Sons, Ltd, Chichester.

7) Gowing et al (2003b). Alpha2 adrenergic agonists for the management of opioid withdrawal. (Cochrane review). In: the Cochrane library. John Wiley & Sons, Ltd, Chichester.

8) Meltzer, H., Gill, B. & Pettigrew, M. (1995) .The Prevalence of Psychiatric Morbidity among Adults Aged 16–64, Living in Private Households in Great Britain. London: HMSO.

9) Rastrick et al (1999) .Tackling Alcohol Together. London, Free Association Books

10). Royal College of Psychiatrists (2002). Advice to commissioners

and purchasers of modern substance misuse services.

12) Royal College of Psychiatrists (2002) .Role of Consultants with Responsibility for Substance Misuse. Addiction Psychiatrists.

13) Sgouros X, et al (2004). Evaluation of a clinical screening instrument to identify states of thiamine deficiency in inpatients with sever alcohol dependence syndrome. Alcohol  Alcohol; 39: 227-232.

14) Shaw G (1995) .Detoxification: the use of benzodiazepines. Alcohol Alcohol; 30:765-70

15) Williams D, Mc Bride A (1998). The drug treatment of alcohol withdrawal symptoms, a systematic review. Alcohol Alcohol; 33: 103-115.

 

Dr Mohammed Ashir

Specialist Registrar in Psychiatry

Royal London Hospitals,

2A Bow Road ,London ,

E3 4LL

 

Dr Sheriff Orekan

Specialist Registrar in Psychiatry

Basildon Hospital

Basildon, Essex

SS16 5NL

 

 


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