devon drug service partnership between dpt & edp devon shared care icp contactable by e-mail...
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DEVON DRUG SERVICEPartnership between DPT & EDP
Devon Shared Care ICPContactable by e-mail marked
GP SHARED CARE URGENT REPLY REQUIREDmary.rowlands@nhs.net or
01392 208210/9
Dr Mary RowlandsConsultant Addiction Psychiatrist implementing governance in shared care Honorary Lecturer, Peninsula Medical School
DEVON DRUG SERVICEPartnership between DPT & EDP
My special interest in Devon…….
has been the teaching of doctors for the development of substance misuse to be embedded throughout the entire medical undergraduate curriculum[ which is now being achieved by a national funded PMS substance misuse champion]
to provide post-graduate practical experience of primary and secondary care doctors in substance misuse , and the development of NMPs.
DEVON DRUG SERVICEPartnership between DPT & EDP
Tier 3 Services
• GP-led substitute prescribing (“shared care”)
•Specialist substitute prescribing & detoxification
•Psychosocial interventions
•(1:1 & group-drug workers)
DEVON DRUG SERVICEPartnership between DPT & EDP
Tier 3 Delivery Staff
• Care co-ordinator
• Support Worker & GP Service User
DDS Support Worker
Care Co-ordinator
GP
DEVON DRUG SERVICEPartnership between DPT & EDP
Specialist Services
• Focus on complex cases
• Role to stabilise drug users with a view to moving on in treatment
• Low threshold prescribing
• Severe & enduring mental health issues alongside drug use
• Inpatient stabilisation, detox and access to rehab
DEVON DRUG SERVICEPartnership between DPT & EDP
Primary Care (GP) Prescribing
•Engage more GPs with primary care prescribing
•Emphasis on throughput & needs-led treatment
•Strengthened governance in shared care
DEVON DRUG SERVICEPartnership between DPT & EDP
Shared CareCare coordinated
intervention to include prescribing intervention
and psychosocial package of support.
Specialist PrescribingCare coordinated
intervention to include prescribing intervention
and psychosocial packaged support.
Tier 2Harm reduction
intervention needle and syringe provision
preparation for change.
Residential Rehab
Preparation for Residential Rehab
Client reviewed on a regular basis by care
coordinator and support worker.
Drug screened and risk assessed.
Client stabilised
meets criteria for
shared care.
Client fails to stabilise – review and
consider Low Threshold
prescribing.
Review if client requires
prescribing intervention.
Discharged
Successful discharge client ends treatment.
Client destabilises transfer to specialist
prescriber until stabilised.
Complicated -complete prescribing
needs or risk management issues
requiring ongoing specialist prescribing
intervention.
Reviewed
Treatment Options Pathway for Service Users Requiring Prescribing Intervention
Triage Assess Comprehensive Assessment
DEVON DRUG SERVICEPartnership between DPT & EDP
ICP Shared Care evolving 2010-13
Triage assessmentAllocation to Care Coordinator (CC)
Starts care plan Liaises with GP to agree shared care
CC coordinates Prescribing assessments
DEVON DRUG SERVICEPartnership between DPT & EDP
Care Coordinator coordinates
Client programme Rx & ψosocial engagement
4way S/C Pharmacy agreementBasis of clinical governance, pharmacist communicate to CC script non compliance
Prescriber & Pharmacist liaise to manage script & communicate to client urgentlyre-failed pick-up, or intoxication=holding script & urgent review
DEVON DRUG SERVICEPartnership between DPT & EDP
From April 2010, at stabilisation dose, GP handover with experience gradual handover of initiation of Integrated Pathway steps
Repeat prescribing (GP) 2 weekly CC/GP drug tests ↓frequency depends on progress
DEVON DRUG SERVICEPartnership between DPT & EDP
Pharmacy collection
Supervised consumption for3/12Pharmacy reports non-collection
& CC checks monthly
>3 non-collection CC holds PXcontacts SU to check not too intoxicated to collect
>5 non-collection GP to re-titrate dose
DEVON DRUG SERVICEPartnership between DPT & EDP
3 monthly 3 way meeting
GP/CC/SUSU=Service User
Stablisation For ~6-12 months
UnstableDOH guidanceMore intense psychosocial
review Px
DEVON DRUG SERVICEPartnership between DPT & EDP
Total destabilisation after re-titrations or other reasons
Check motivation Suitability for Tier 3
Further secondary care reviewOr low threshold Px
DEVON DRUG SERVICEPartnership between DPT & EDP
DOH Orange Book UK clinical management guidelines
Chapter 2 Clinical Governance * Chapter 4 ψosocial treatment * Chapter 5 Pharmocological treatment* Chapter 6 Health Considerations
Appendices Cardiac monitoring* Drugs & driving Prescription Management
DEVON DRUG SERVICEPartnership between DPT & EDP
Chapter 2 Clinical Governance
Clinical Effectiveness Competencies/CPD
Recognition of high risk populations
Increasing competency to deal with non-complex general then special populations [Chapter 7]
Working as a Team Information
management Information
sharing/safeguarding Records/data
collection with feedback
Public Health Disease prevention Health promotion Address health
inequalities
DEVON DRUG SERVICEPartnership between DPT & EDP
Working as a Team
Primary Care Partner cover Primary Care Receptionist awareness Back up of secondary care, if
complexity increases after orange book strategies on improving engagement or managing risk do not succeed
DEVON DRUG SERVICEPartnership between DPT & EDP
Recovery Model
Psychosocial Program assistsgraduated reduction if stable
Relapse Prevention & SU life recovery
DEVON DRUG SERVICEPartnership between DPT & EDP
Key clinical governance messages for on-going prescribing
Prescribe within an evidenced dose range Risk awareness
Sedative overdose-BNZ &/or Alcohol QT prolongation
Methadone dose-related Concurrent ψtropic prescribing
Basic monitoring of non-collection 3 days,>5 days
ψosocial engagement is necessary as well as a script is the message to clients
3 monthly review Stabilisation → Detoxification readiness
DEVON DRUG SERVICEPartnership between DPT & EDP
People do achieve abstinence
Treatment evidence• DATOS: 28% of intake sample defined as ‘recovered’ 5 years after the start of the index treatment(no use of opioids or cocaine and no criminality)
• Combining UK and US evidence:– 10-15% of treatment seekers achieve abstinence at 1 year– more than 25% by five years– 66% twelve years after initiating treatment
DEVON DRUG SERVICEPartnership between DPT & EDP
DEVON DRUG SERVICEPartnership between DPT & EDP
DEVON DRUG SERVICEPartnership between DPT & EDP
DEVON DRUG SERVICEPartnership between DPT & EDP
Does adding psychosocial therapyto OST improve outcomes?• Amato et al (2009): 28 trials and 2945 participants
• No. of participants abstinent at the end of follow up (5 trials) and continuous weeks of abstinence (2 trials) showed a benefit in favour of the associated treatment
• Psychosocial Treatment for Drug Misuse (NICE, 2008):evidence for– Contingency management for people in OST (strongly and consistently associated with longer, continuous periods of abstinence during treatment and abstinence at 6- and 12-month follow-up)– Behavioural-couples therapy and family-based interventions (associated with reductions in illicit drug use)
DEVON DRUG SERVICEPartnership between DPT & EDP
Does adding psychosocial therapyto OST improve outcomes?
• Organisational Factors
• Large differences in the treatments offered by individual services• DATOS showed many methadone programmes do not provide sufficient range or intensity of counselling to meet their patients’ needs• Big differences in the effectiveness of different treatment programs• Some services do a better job of engaging and retaining patients, and such services also show better gains in psychosocial functioning by their patients
DEVON DRUG SERVICEPartnership between DPT & EDP
• Gp is the long-term therapist in terms of empathy
DEVON DRUG SERVICEPartnership between DPT & EDP
DEVON DRUG SERVICEPartnership between DPT & EDP
DEVON DRUG SERVICEPartnership between DPT & EDP
UK Substance Misuse Treatment Workers’Attitudes to Twelve-Step Self-Help Groups
Day E, Gaston R, Furlong E, Murali V, Copello A.Journal of Substance Abuse Treatment 2005 29;321-327
DEVON DRUG SERVICEPartnership between DPT & EDP
DEVON DRUG SERVICEPartnership between DPT & EDP
Outcomes for clients
•Optimistic treatment planning: aiming for abstinence from Problematic Drug use, with 12 months intensive ψosocial treatment then intervention
•Client feedback & accurate “whole-life” mapping of outcomes. Clients should manage their own lives
•Ψosocial development of client tools to use as part of aftercare
•WRAP wellness recovery action plan, builds in clinical governance re-dangers of a loss of
tolerance
DEVON DRUG SERVICEPartnership between DPT & EDP
DEVON DRUG SERVICEPartnership between DPT & EDP
Any Questions?
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