Drug TreatmentDrug Treatment

andand

PrescribingPrescribing

Vincent HesseyVincent Hessey

DANOS UNITSAA3, AC1, AC3, AD1, AD4

• Understand the impact of substance misuse in the locality.

• Be aware of services commissioned to respond to the above.

• Understand how the service operates strategically and on a day to day basis.

• Understand how to access the service and treatments available.

WALLASEY

BIRKENHEAD

WEST WIRRAL

Wirral MapWirral Map

WIRRAL DRUG SERVICE WIRRAL POPULATION circa 312,293 (census 2001)WIRRAL POPULATION circa 312,293 (census 2001) HEROIN ‘EPIDEMIC DURING’ 1980’sHEROIN ‘EPIDEMIC DURING’ 1980’s 4475 DRUG USERS = 2.3 % of total population *4475 DRUG USERS = 2.3 % of total population * WIRRAL HIV/AIDS PREVENTION UNIT( 1988)WIRRAL HIV/AIDS PREVENTION UNIT( 1988) WIRRAL DRUG SERVICE (1991)WIRRAL DRUG SERVICE (1991) CLIENTS IN TREATMENT 1500 (0.51% pop)CLIENTS IN TREATMENT 1500 (0.51% pop)

* 15-64 years population 195,566 source Centre for Public Health LJMU May 2003 > Ratio ( 1in) 1-43

MISSION STATEMENTWIRRAL DRUG SERVICE PROVIDES QUALITY ACCESSIBLE WIRRAL DRUG SERVICE PROVIDES QUALITY ACCESSIBLE

INTERVENTIONS FOR THOSE WHOSE LIVES ARE INTERVENTIONS FOR THOSE WHOSE LIVES ARE AFFECTED AFFECTED

BY DRUG USE, TREATING THEM WITH DIGNITY AND BY DRUG USE, TREATING THEM WITH DIGNITY AND RESPECT. RESPECT.

THE SERVICE RESPONDS TO THE DIVERSITY OF THE THE SERVICE RESPONDS TO THE DIVERSITY OF THE COMMUNITY COMMUNITY

AND RECOGNISES THE NEEDS OF INDIVIDUAL CLIENTS, AND RECOGNISES THE NEEDS OF INDIVIDUAL CLIENTS, THEIR THEIR

FAMILIES AND CARERS. FAMILIES AND CARERS.

NTA MID YEAR REVIEW MEETING

A more recent piece of research focussing on drug treatment from a drug users perspective, commissioned by the DAAT, has further confirmed that as far as substitute prescribing is concerned, Wirral’s drug treatment system is probably as good as it gets. That is not to say however, that things should remain as they are indefinitely.

Prescribing lies at the heart of any drug treatment system and will continue to remain so as described in the Governments New Drug Strategy; the prescribing system delivered across the Wirral and in particular by the Cheshire and Wirral NHS Foundation Trust, remains one of the most pragmatic, flexible and humane regimes we have encountered.

The NTA look forward to assisting Wirral's drug treatment system to evolve over the future lifetime of this new drug strategy and we expect it to remain one of the most effective drug treatment systems the NTA currently oversees

Wirral continues to be one of our best performers and probably represents the very best approach to tackling drug misuse that the Governments last Drug Treatment Strategy aspired to. The New Drug Strategy will certainly mean change and evolution for Wirral's drug treatment system but we remain assured and confident that it is already responding to the challenge that the new drug strategy represents.

MARK HARRISNW DEPUTY REGIONAL MANAGERNATIONAL TREATMENT AGENCY

HOSPITALREFERRAL

GPREFERRAL

SHARED CARE&

RECOVERYTEAM

TRIAGEASSESSMENT

REVIEW S

THEREVIEW

TEAM

CRIMINAL JUSTICESOCIAL CARE

HOSTELSPD CASELOAD

HARMREDUCTIO N

TEAMR

DUAL DIAGNOSISPSYCHOLOGIST

COMPLEX CLIENTSYOUNG PEOPLE

THEPROJECTS

TEAM

FULLDRUG

ASSESSMENT

SELFREFERRAL

OTHERAGENCY

W IRRALDRUG

SERVICE

DRUG PATHWAYDRUG PATHWAY

TreatmentExit

Team

OTCDual Diagnosis

PD CaseloadPsychologist

4 YO

Criminal JusticeHostels

Young PeopleSocial Care

ASSESSMENT REASONS FOR PRESENTATIONREASONS FOR PRESENTATION DRUG HISTORY (PAST & PRESENT)DRUG HISTORY (PAST & PRESENT) HISTORY OF INJECTING (HIV, HEP C)HISTORY OF INJECTING (HIV, HEP C) MEDICAL HISTORYMEDICAL HISTORY PSYCHIATRIC HISTORYPSYCHIATRIC HISTORY FORENSIC HISTORY FORENSIC HISTORY SOCIAL HISTORYSOCIAL HISTORY PAST CONTACT WITH SERVICES PAST CONTACT WITH SERVICES URINALYSISURINALYSIS OTHER INFORMATIONOTHER INFORMATION

ASSESSMENT

EXAMINATION MOTIVATIONMOTIVATION GENERAL HEALTHGENERAL HEALTH MENTAL HEALTHMENTAL HEALTH

SOCIAL CIRCUMSTANCESSOCIAL CIRCUMSTANCES FAMILY ISSUESFAMILY ISSUES HOUSING / HOMELESS PROBLEMSHOUSING / HOMELESS PROBLEMS(DRUGS MISUSE and DEPENDENCE - CLINICAL GUIDELINES)

REASONS FOR PRESCRIBING IMPROVE CLIENTS HEALTHIMPROVE CLIENTS HEALTH REDUCE DRUG USE ( ILLICIT & PX)REDUCE DRUG USE ( ILLICIT & PX) ADDRESS DRUG RELATED PROBLEMSADDRESS DRUG RELATED PROBLEMS REDUCE DRUG RELATED HARM / DEATHSREDUCE DRUG RELATED HARM / DEATHS REDUCE DURATION OF DRUG USE EPISODESREDUCE DURATION OF DRUG USE EPISODES REDUCE CHANCE OF FUTURE RELAPSEREDUCE CHANCE OF FUTURE RELAPSE REDUCE NEED FOR CRIMINAL ACTIVITY REDUCE NEED FOR CRIMINAL ACTIVITY REDUCE RISK OF PRESCRIBED DRUGSREDUCE RISK OF PRESCRIBED DRUGS BEING SOLD ILLEGALLY BEING SOLD ILLEGALLY

ASSESSING MOTIVATION

Rather than testing whether the applicant Rather than testing whether the applicant “really” wants to change, clinicians should “really” wants to change, clinicians should welcome the opportunity to demonstrate to welcome the opportunity to demonstrate to clients the benefits of treatment. The challenge clients the benefits of treatment. The challenge in drug treatment should not be to test in drug treatment should not be to test motivation, but to foster it, and to maximise the motivation, but to foster it, and to maximise the likelihood that the individual will benefit from likelihood that the individual will benefit from treatment.treatment. KEY ISSUES IN METHADONE MAINTENANCE TREATMENT

JEFF WARD, RICHARD MATTICK, WAYNE HALL

METHODS OF PRESCRIBING METHADONE MIXTURE 1mg/1ml, 10mg/1mlETHADONE MIXTURE 1mg/1ml, 10mg/1ml METHADONE REEFERS 30mg, 60mg.METHADONE REEFERS 30mg, 60mg. METHADONE AMPOULES 50, 35, 20, 10 mgMETHADONE AMPOULES 50, 35, 20, 10 mg METHADONE TABLETS 5mgMETHADONE TABLETS 5mg DIAMORPHINE AMPOULES / REEFERSDIAMORPHINE AMPOULES / REEFERS BUPRENORPHINE (SUBUTEX)BUPRENORPHINE (SUBUTEX) BENZODIAZEPINESBENZODIAZEPINES ANTIDEPRESSANTS / ANTIPSYCHOTICSANTIDEPRESSANTS / ANTIPSYCHOTICS LOFEXEDINE / NALTREXONELOFEXEDINE / NALTREXONE

WHAT TO PRESCRIBE

ASCERTAIN ILLICIT DRUG USEASCERTAIN ILLICIT DRUG USE INITIAL DOSAGE (30 mg)INITIAL DOSAGE (30 mg) SUPERVISED CONSUMPTIONSUPERVISED CONSUMPTION ORAL METHADONEORAL METHADONE DAILY PICK UPDAILY PICK UP TITRATE DOSAGETITRATE DOSAGE REVIEW REVIEW

POLICIES AND PROCEDURES

MISUSE of DRUGS ACT 1971MISUSE of DRUGS ACT 1971 CHILDREN ACT 1989/2004CHILDREN ACT 1989/2004 TACKLING DRUGS (Government Strategy)TACKLING DRUGS (Government Strategy) NATIONAL TREATMENT AGENCYNATIONAL TREATMENT AGENCY MODELS OF CARE MODELS OF CARE CLINICAL GOVERNANCE (PRCISE)CLINICAL GOVERNANCE (PRCISE) DANOS DANOS QUADSQUADS

REVIEW KEYWORKER /CLIENT - 3/12KEYWORKER /CLIENT - 3/12 ASSESS DRUG USEASSESS DRUG USE ASSESS CURRENT MEDICATIONASSESS CURRENT MEDICATION REVIEW HEALTH / MENTAL HEALTHREVIEW HEALTH / MENTAL HEALTH SOCIAL CIRCUMSTANCES / PROBLEMSSOCIAL CIRCUMSTANCES / PROBLEMS CHILD PROTECTION ISSUESCHILD PROTECTION ISSUES FORENSICFORENSIC EMPLOYMENT STATUSEMPLOYMENT STATUS CLIENT MOTIVATIONCLIENT MOTIVATION CARE PLAN/ RISK ASSESSMENT/ URINECARE PLAN/ RISK ASSESSMENT/ URINE

DOCTORS REVIEW DOCTORS REVIEW 6/12DOCTORS REVIEW 6/12 ASSESS CURRENT PRESCRIPTION ASSESS CURRENT PRESCRIPTION ASCERTAIN CURRENT DRUG USEASCERTAIN CURRENT DRUG USE ADDRESS HEALTH / MENTAL HEALTHADDRESS HEALTH / MENTAL HEALTH REFER TO OTHER SERVICESREFER TO OTHER SERVICES CARE PATHWAY APPROACHCARE PATHWAY APPROACH INCREASE / DECREASE SCRIPTSINCREASE / DECREASE SCRIPTS DISCUSS FUTURE PLANSDISCUSS FUTURE PLANS

Trans-theoretical Model of Behaviour Change

Preparation stageI prepare to stop/reduce the amount of drugs I use

Action stageI stop using drugs

RelapseI start to use drugs again

Maintenance / RecoveryI continue not to use drugs

PrecontemplationI believe there is no link between drugs and my health

ContemplationI perceive a link between my drug use and my health

Prochaska and DiClemente’s Wheel of Change (1991)

Precontemplation -- Where there is no intention to change behaviour in the foreseeable future .

Contemplation -- Where there is awareness that a problem exists and one is seriously thinking about overcoming it but has not yet made a

commitment to take action.

Preparation -- Where the person is intending to take action soon and may have already unsuccessfully taken action during the past year.

Action -- Where the person modifies the behaviour, putting in a considerable amount of time

and energy, which is obvious to others.

Maintenance -- Where the person works to prevent relapse and consolidates the gains of the action

stage. This stage may go on for a long time, possibly a lifetime.

REVIEW TEAMSREVIEW TEAMS

• 400 CLIENTS• 8 WORKERS• ENGAGEMENT /OUTREACH WORKERS• REVIEW CASELOADS• DIAMORPHINE TREATMENT

PROJECTS TEAM

• 275 CLIENTS

• CRIMINAL JUSTICE PRACTITIONER

• HOSTELS/HOMELESS & YOUNG PERSONS LINK WORKER

• SOCIAL CARE CASELOAD / CO-ORDINATOR

• SUBSTANCE MISUSE WORKER

PROJECTS TEAMDUAL DIAGNOSIS / MENTAL HEALTH NURSE

CLINICAL PSYCHOLOGIST(PERSONALITY DISORDERS)

4 YEARS + CLIENTS (4YO)

SUBSTANCE MISUSE PRACTITIONER (PERSONALITY DISORDERS)

OVER THE COUNTER PRACTITIONER

HARM REDUCTION CENTREHARM REDUCTION CENTRE• NURSE LED SERVICE• NURSE PRESCRIBING• HEP C PATHWAY NURSE• HOMELESS NURSE PRACTITIONER• SYRINGE EXCHANGE• CONFIDENTIAL TESTING• SEXUAL HEALTH CLINIC• STEROID CLINIC• STIMULANT NURSE• WOMENS SERVICES• ALCOHOL NURSE PRACTITIONER• PHARMACY LIAISON WORKER

WIRRAL DRUG SERVICE

SHARED CARE & RECOVERY TEAMSHARED CARE & RECOVERY TEAM

• 16 WORKERS• 780 CLIENTS (700/80)• 100% WIRRAL GP’S• GP TRAINING• RCGP ACCREDITATION

WIRRAL DRUG SERVICE

SHARED CARE & RECOVERY TEAMSHARED CARE & RECOVERY TEAM

• VARIETY OF PRESCRIBING OPTIONS• ALTERNATIVE THERAPIES• DETOX TRANSITION• RECOVERY PROGRAMMES• REFER TO AFTERCARE

Treatment Exit Team

• Stable Clients• Reducing off Script• Regular Contact• Therapeutic Interventions• Prepared to exit within 3-6 months as

drug free

REFERENCES & LINKSDRUGS MISUSE and DEPENDENCE - CLINICAL GUIDELINES

DOH PUBLICATION

TACKLING DRUGS TO BUILD A BETTER BRITAIN (1998)

WWW.WIRRALDRUGSERVICE.ORG

METHADONE BRIEFING (ANDREW PRESTON)

KEY ISSUES IN METHADONE MAINTENANCE TREATMENT

( JEFF WARD, RICHARD MATTICK, WAYNE HALL )

Applications to Addictive Behaviours, (James 0. Prochaska, Carlo C. DiClemente and John C. Norcross) (pp. 1102-1114 Vol. 47, No. 9), (1991)

FIRST INTERNATIONAL CONFERENCE ON HARM REDUCTION

(Newcombe,1991)

INSTITUTE FOR STUDY OF DRUG DEPENDENCE (1996)