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Devon Shared Care ICP

Devon Shared Care ICP. Contactable by e-mail marked GP SHARED CARE URGENT REPLY REQUIRED mary.rowlands@nhs.net or 01392 208210/9. Dr Mary Rowlands Consultant Addiction Psychiatrist implementing governance in shared care Honorary Lecturer, Peninsula Medical School.

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Devon Shared Care ICP

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  1. Devon Shared Care ICP Contactable by e-mail marked GP SHARED CARE URGENT REPLY REQUIRED mary.rowlands@nhs.netor 01392 208210/9 Dr Mary Rowlands Consultant Addiction Psychiatrist implementing governance in shared care Honorary Lecturer, Peninsula Medical School

  2. 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.

  3. Tier 3 Services • GP-led substitute prescribing (“shared care”) • Specialist substitute prescribing & detoxification • Psychosocial interventions • (1:1 & group-drug workers)

  4. Care Co-ordinator Service User DDS Support Worker GP Tier 3 Delivery Staff • Care co-ordinator • Support Worker & GP

  5. 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

  6. Primary Care (GP) Prescribing • Engage more GPs with primary care prescribing • Emphasis on throughput & needs-led treatment • Strengthened governance in shared care

  7. Treatment Options Pathway for Service Users • Requiring Prescribing Intervention • Triage Assess • Comprehensive Assessment Specialist Prescribing Care coordinated intervention to include prescribing intervention and psychosocial packaged support. Tier 2 Harm reduction intervention needle and syringe provision preparation for change. Residential Rehab Shared Care Care coordinated intervention to include prescribing intervention and psychosocial package of support. Preparation for Residential Rehab Reviewed Client stabilised meets criteria for shared care. Client fails to stabilise – review and consider Low Threshold prescribing. Review if client requires prescribing intervention. Client reviewed on a regular basis by care coordinator and support worker. Drug screened and risk assessed. Discharged Complicated - complete prescribing needs or risk management issues requiring ongoing specialist prescribing intervention. Successful discharge client ends treatment. Client destabilises transfer to specialist prescriber until stabilised.

  8. ICP Shared Care evolving 2010-13

  9. Care Coordinator coordinatesClient programme Rx & ψosocial engagement Prescriber & Pharmacist liaise to manage script & communicate to client urgently re-failed pick-up, or intoxication =holding script & urgent review 4way S/C Pharmacy agreement Basis of clinical governance, pharmacist communicate to CC script non compliance

  10. 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

  11. Pharmacy collection

  12. Total destabilisation after re-titrations or other reasons

  13. 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

  14. 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 Chapter 2 Clinical Governance

  15. 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

  16. Recovery Model

  17. 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

  18. 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

  19. Does adding psychosocial therapy to 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)

  20. Does adding psychosocial therapy to 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

  21. Gp is the long-term therapist in terms of empathy

  22. 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

  23. 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

  24. Any Questions?

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