Injectable opioid prescribing in Oxfordshire

We sought to replicate in the Specialist Community Addiction Service that covers the county of Oxfordshire the audit on the prescribing of injectable opiates undertaken by White & Shearman in Cornwall. ¹ We identified 19 patients (14 males and 5 females) on regular injectable opioid prescriptions: 10 on diamorphine (53%), 5 on methadone (26%), 2 on pethidine (11%) and 1 on morphine (5%); 1 person dropped out of the service and was not further included in the study. Of these, 17 were interviewed using a slightly modified version of the audit tool kindly provided by White & Shearman. Only one person had been started on a script in the past 4 years while others had been on this type of treatment for an average of 9.5 years (s.d. = 4.1). Three patients, all females, had been dependent on prescribed injectable opioid analgesics. The other 14 had been heroin users for an average of 15.8 years (s.d. = 6.3) before being started on an injectable prescription. Compared with Cornwall, our audit reveals an older group of users who had been started on injectable scripts after lengthy periods of oral substitution treatment (average 9.2 years, s.d. = 6.1). The Oxfordshire cohort was also relatively more stable with no reports of overdoses while using the prescribed drug or additional opiate use in the previous month. Alcohol consumption was also low, with only two clients reporting problematic levels of drinking. When asked, 47% said they had no intention to ever come off the script; 29% would consider it in 5 years and 24% in 1 year. The clients, regardless of the drug injected, were approximately evenly split between almost exclusive intramuscular or intravenous use with little crossover. Around half the patients reported experiencing any harmful physical consequences from prescribed injectable opiates. Occasional abscesses were the main problem faced by those injecting intramuscularly, whereas those who practised intravenous injections reported abscesses, deep vein thrombosis and cellulitis. All had found access to medical care when needed. The overwhelming majority claimed to consistently use clean needles but the answers were more equivocal with regard to sterile injecting technique. Direct supervision of injecting techniques was minimal with only two clients (11%) remembering having been observed on one occasion by their general practitioner or another health professional. In conclusion, we found interesting similarities between the client groups in Oxford and Cornwall, which might indicate that a clinical rationale for providing injectable opiates to a niche population exists and that it transcends geographical and social regional differences.