devon drug service partnership between dpt & edp devon shared care icp contactable by e-mail...

DEVON DRUG SERVICEPartnership between DPT & EDP

Devon Shared Care ICPContactable by e-mail marked

GP SHARED CARE URGENT REPLY [email protected] or

01392 208210/9

Dr Mary RowlandsConsultant Addiction Psychiatrist implementing governance in shared care Honorary Lecturer, Peninsula Medical School


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.


Tier 3 Services

• GP-led substitute prescribing (“shared care”)

•Specialist substitute prescribing & detoxification

•Psychosocial interventions

•(1:1 & group-drug workers)


Tier 3 Delivery Staff

• Care co-ordinator

• Support Worker & GP Service User

DDS Support Worker

Care Co-ordinator

GP


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


Primary Care (GP) Prescribing

•Engage more GPs with primary care prescribing

•Emphasis on throughput & needs-led treatment

•Strengthened governance in shared care


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


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


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


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


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


3 monthly 3 way meeting

GP/CC/SUSU=Service User

Stablisation For ~6-12 months

UnstableDOH guidanceMore intense psychosocial

review Px


Total destabilisation after re-titrations or other reasons

Check motivation Suitability for Tier 3

Further secondary care reviewOr low threshold Px


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


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


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


Recovery Model

Psychosocial Program assistsgraduated reduction if stable

Relapse Prevention & SU life recovery


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


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


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)


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


• Gp is the long-term therapist in terms of empathy


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


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


Any Questions?

devon drug service partnership between dpt & edp devon shared care icp contactable by e-mail...

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