By Dr Tracey Myton MRCPsych
Consultant Addiction Psychiatrist
Greater Manchester Mental Health NHS Foundation Trust
March 2020 seems like a lifetime ago. Coronavirus came nearer and nearer and was viewed with varying degrees of gravity whilst we went about our daily business. In mid-March we were called to seriously consider how our services should change the way treatment was delivered. This apparently highly contagious virus causing respiratory failure and death, particularly in men, seemed likely to target our patient group. Most are men in their 40s and 50s; they generally started smoking cigarettes around the age of eight and have a diagnosis of COPD. They have poor diets, commonly go in and out of hospital with pneumonia, sometimes leading to premature death. We all anticipated that such patients, if infected with COVID-19, were at high risk of serious respiratory symptoms and death.
Until the COVID crisis the policy regarding opiate substitution treatment (OST) was that of supervised consumption ie the practice of patients attending community pharmacies daily and taking their methadone or buprenorphine under the supervision of the pharmacist to ensure that patients received the correct safe dose. Our leadership team agreed that there was no option but to reduce pharmacy collections for as many patients as possible, with the aim to implement this by the end of the month. Most patients had been collecting daily, often supervised. The plan was to move them to weekly collection as quickly as possible. Substance misuse services (SMS) around the country did the same. There has been much reflection on the relaxation of supervised consumption. Perhaps this has empowered patients to take control of their own recovery.
The Recovery Co-ordinators worked hard to identify those on their caseload who were not considered safe to receive weekly collections. Prescriptions were altered electronically and by hand. I did some of this by visiting the pharmacies myself to expedite things. This was an excellent opportunity to meet pharmacists who mostly knew me by my signature only; they were invariably helpful, grateful for the swift response and keen to keep our mutual patients and their own staff as safe as possible.
We did recognise the risks associated with this sudden lenience and lockable boxes were delivered to pharmacies and patients’ homes as well as nasal naloxone. We have never found injectable naloxone to be popular; often refused on the basis of reminding past injectors of injecting. The nasal naloxone is expensive but could legitimately be charged to the seemingly bottomless ‘COVID budget’. Recovery Co-ordinators contacted their caseload and delivered harm-reduction advice, specifically related to the pandemic. Some patients seemed blissfully unaware that there was a pandemic, a few were highly anxious.
During that first week or two after Lockdown, it was amusing to see new heroin users for assessment for Opiate Substitution Therapy (OST) and, in the absence of any risk, give them a prescription for a week’s supply of methadone. Most of our ‘new’ patients have considerable experience of treatment (just as much as we have in treating them) and were astonished at this sudden relaxation of the rules. They seemed truly bemused by our concern about the risk to them and thought it was Christmas! Perhaps the tone of our consultations became more collaborative; perhaps this was wishful thinking. I heard the phrase ‘we are helping you to keep yourself safe’ many times; the paternalism of supervised consumption seemed simply to have transmuted. It is just possible that our patients are responsible adults, competent to take care of their own health and well-being and that of their families, without supervision, lockable boxes or naloxone. Still, I was concerned that the town would be flooded with illicit methadone which essentially had my name on it.
Thankfully, the deaths amongst those in our treatment services, that we confidently predicted, do not seem to have occurred. There have been deaths, certainly, but not significantly more than usual and not largely as a result of the virus.
During subsequent months, listening to anecdotes from patients who do come into service, illicit methadone is a bit easier to obtain. The cost of it does not seem to have reduced and my sense is that most patients are taking their own methadone, as prescribed. There were tales of it being stolen, lost and the bottles broken and undoubtedly a few vulnerable adults were exploited. There do not seem to have been an increase in deaths from accidental or deliberate methadone overdoses, although since Inquests are also delayed, it may be a while before we know for certain.
The quality of heroin is said to have reduced because of an interruption in the supply chain. This might account for the adherence to prescribed medication.
By mid-April, there appeared to be a sudden calm. There were fewer new referrals, fewer assessments, no ‘routine’ reviews and our focus seemed unclear. Most contacts with patients were by telephone which was more efficient. Those needing to come into the service found waiting rooms far quieter with far less raised voices or frustrated aggression and interactions with all staff seemed friendlier and more cooperative. There was an apparent appreciation that the service was open at all. Patients coming into my office for assessment still seem entertained. to be faced with a masked doctor in surgical scrubs and some suggest that I might be over-reacting.
Some patients have been difficult to reach; they did not answer their phones and staff were concerned for their well-being. Outreach teams visited them at home if necessary, some prescriptions were suspended to encourage contact, but these seemed the minority. Our patients lead chaotic, disrupted lives and our part in their lives is less of a priority than we like to think. A pandemic of a few months will not change that.
Recovery groups and mutual aid has responded admirably to the need to work differently. Alcoholics Anonymous and Narcotics Anonymous provided virtual groups almost immediately. Psychosocial Intervention Teams within SMS who traditionally deliver most therapy in groups found this a little more difficult. Some patients have responded well, others do not possess the IT equipment or skills to access virtual support; existing inequalities have been further widened. We are gradually reintroducing face-to-face groups where it is possible.
The advantages of working within the NHS become swiftly apparent: back-up and support from infection control teams, assessment of premises with implementation of social distancing, PPE, other sensible measures, sometimes ahead of Government recommendations and the IT to enable home-working. Third sector SMS providers presumably had far less expertise..
Early in the pandemic, background increasing death rates in other European countries led our trust to consider that sickness form virus and self-isolation would drastically affect workforce; this didn’t actually materialise, again thankfully. Some staff have self-isolated and worked from home, many of us have reported improvements in our daily routines – less traffic, encouragement to work at home whenever possible and COVID-camaraderie. Staff sickness has paradoxically reduced; the unprecedented wave of appreciation for the NHS has surely contributed to this.
Staff anxiety has taken up a lot of my time. Most ‘Recovery Co-ordinators’ no longer have a professional background, we have far fewer nurses in SMS than we did ten years ago, it felt that despite strong leadership some staff were making less reasoned calculation of the risk COVID-19 would put them at. Directives from above suggesting how we should manage our own anxieties and that of our children seemed to be an added pressure.
Working for the NHS at this time has been an interesting experience. I have been fortunate to be able to practise addiction psychiatry in the NHS for twenty years, whilst some respected and dedicated colleagues have had little choice but to work for the third sector. The unaccustomed lauding of the NHS and the strange celebrity status that an NHS ID card conferred in supermarkets took us by surprise. ‘Thank you Thursdays’ sprung up and left me feeling somewhat of an imposter; I was ‘just’ a psychiatrist doing my usual job, not ‘battling to save lives’ on Intensive Care. Despite all the work done in recent years on reducing the stigma of mental illness, it seemed that mental health clinicians and managers consider that their jobs were not just quite as important as those done on the ‘Front Line’ by acute Trusts. Most of my medical friends and peers thought that had the NHS been properly funded in the first place, all this rhetoric would not have been necessary.
I am cautiously optimistic. I would be in the wrong job if I wasn’t. I hope that the opportunities this pandemic has brought: different ways of working, less restrictive prescribing, the emergence of a new way of relating to our patients might enable them to move towards a life without drugs. We must be certain we have the data to demonstrate safety and effectiveness before concluding that we are ‘building back better’.