Shared Care – In PracticeDr Sue Pritchard

Shipston Medical Centre

Chronic relapsing condition – similar to others treated in primary care

Mortality 14 x higher for age matched controls

Morbidity: 90% cases of hep C in UK are associated with IVD use

Substance misuse treatment in primary care- why bother?

Effective evidence based treatment with good outcomes

Needs holistic individualised approach – cornerstone of GP care

Good for our communities

Why bother….

Physical: BBV transmission, complications of injecting including VTE, abscesses, Endocarditis, Poor pregnancy outcomes, Overdose.

Social: Effects on families, criminality, imprisonment, social exclusion

Psychological: Fear of withdrawal, craving , guilt, stigma

Mental health: depression, psychosis, dual diagnosis

Effects of dependant drug use

Reduces mortality significantly Reduced drug related morbidity Reduces crime Reduces risk taking behaviour and spread of BBV Can be done safely without increasing methadone

mortality

Evidence based treatments

RCGP Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care – 2011

Drug misuse and dependence - UK guidelines on clinical management

RCGP Certificate in the Management of Drug Misuse

Guidelines

NTA describes range of interventions which are intended to remedy an identified drug related problem or condition relating to a person’s physical, psychological and social well being

Structured drug treatment follows assessment and is delivered with a written mutually agreed care plan, which is regularly reviewed

What is Treatment?

Political shift towards recovery approach which NTA frames ‘in terms of achieving an individual client’s goals for making positive changes in their lives’.

This is underpinned by more personalised approach to treatment and a balanced system including, even encouraging, abstinence orientated treatment

Treatment and ‘Recovery’

A patient’s unique journey Shared care patients -often stabilised, housed,

employed, family Need opportunity to discuss reduction

‘ Treatment should end at the point of the patient’s journey which the patient and the prescriber judge to be clinically (not politically or morally) safe and appropriate’

Recovery

Philosophy More than just methadone Therapeutic alliance◦Motivational interviewing – Rollnick and Miller

Engagement – attitudinal approach throughout team Holistic approach Family support - ESH Safeguarding Children Safety of medicines DVLA

In Practice New patients seen by SCP/PD Contact previous GP/CDT team CDT full assessment with positive swabs and contract Harm minimisation – Hep C /HIV/Hep B testing, accelerated

Hep A /B vaccination schedule. Overdose prevention advice Needle exchange scheme at local chemist and needle bin at

Ellen Badger Hospital

In practice… Maintenance until stability achieved Regular health check – aging population! COPD/Hep

C/Alcoholic cardiomyopathy Contraception and STIs Cascade alerts re contaminated batches Boundaries – not punitive but consistent Negotiation re pick ups Life without drugs – the role of ‘meaningful activity’

QOF and chronic disease - depression screening questions

Evidence that PHQ9 and GAD score can be used with patients within addiction services.

Improved flexible working with CMHT especially IAPT

In practice

RCGP guidelines:

Treatment reviewed at every contact and needs to be re-examined more formally every 3-4 months to measure improvements in health and wellbeing and to monitor any use of alcohol or drugs and given support to make changes

Toxicology screen frequently at start of treatment and when stabilised two to four times a year.

Ongoing care

Torsades de pointes – ventricular arrhythmia associated with prolonged QTc interval

All those on methadone 100mg or above Those on methadone + additional factors◦ Lithium, SSRI, TCA, sotalol, venlafaxine, macrolides◦ Structural heart disease

◦Offer ECG – if normal, repeat every 12 months◦ If abnormal – discuss change in script, reduction in dose,

consider cardiology referral

High dose Methadone and risk of sudden cardiac death

In practice Therapeutic relationship requires trust and continuity Continuity of CDT worker and GP Positive attitude from Primary health care team Good communication – plans in place, swab results

available Flexibility of CDT worker and GP Engagement and signposting for other psychosocial issues Consistency in approach by other GPs in the practice.

Annual clinical meeting Professional peer support