Tallaght October 2010 Where Are We Now ?

1. TallaghtOctober 2010Where Are We Now ? Margaret Bourke GP Coordinator

2. Partnership • This is the story of what I see as a very successful partnership to provide treatment to a very disadvantaged group in society. Also to bring dignity and caring to the workplace and to provide it to this cohort. Those of you who were here in the early days will remember when treatment was provided in less than ideal venues and we were not provided with a red carpet welcome and serious attempts were made to stop us providing treatment.

3. Addiction • Is a chronic recidivist illness • The object should be a functioning lifestyle on treatment, with abstinence for those who can achieve it. • It is a disease of neuro chemical pathways. Specific opiate receptors have been identified.

4. Changing Attitudes “Addictive disorders should be considered in the category with other disorders that require long-term or life long treatment. The treatment of addiction is about as successful as treatment of disorders such as hypertension, diabetes and asthma. It is clearly cost effective…….and as with treatment of these other chronic conditions there is no cure”

5. Background • The epidemic of heroin in the mid 1980s and the explosion in the 1990s which continues into the 21st century has led to enormous problems with healthcare • Addiction is an illness which needs treatment • There is an increasing need to respond with a statutory duty to provide a multidisciplinary service

6. Advent of HIV • Led to a demand for stabilization and maintenance treatment programs with methadone. • In response, the then Eastern Health Board set up services.(1992) • What commenced as a HIV prevention programme rapidly became a response to the problem of heroin use. • Increasing evidence of Hepatitis C in injecting drug users fueled the need for treatment.

7. Needle Exchange • First Exchange 1988 • Statutory Services 10 • Back Packing • Out Reach • N G O large city centre N E funded by HSE and Private Donations • Tallaght JADD Oct.2002, St. Aengus 203

8. Treatment • Prior to 1992 most treatment was abstinence orientated • Prior to the Protocol most treatment was based in Central Services • Community a Number of Untrained Practitioners Prescribing for a Large Number of Patients

9. Background • Significant Heroin Problem • Problematic use concentrated in Dublin • Advent of HIV Epidemic led to a change in Policy • Harm Reduction Philosophy Embraced • Most Treatment Methadone Maintenance

10. Central Service • Addiction Treatment Centers • Satellite Clinics • Drug Treatment Centre • Prisons • Cuan Dara

11. CentralTreatment Services • August 1992 first Addiction Treatment centers opened. There are now 23 centers in the Dublin area. • March 1995 first Satellite clinic opened in Tallaght. There are now 43 such clinics in the Dublin area. • The Drug Treatment Centre (Trinity Court)

12. Addiction Treatment Centre • More Challenging Patient Cohort • Polydrug Use - Alcohol, Benzodiazepine,Cocaine • MultidiscipliniaryTreatment Team • On Site Dispensing

13. Developments Treatment Centers • Have increased in number from the two opened in 1992 to twelve with the agreement of local communities. • Staffed by G.P.S specialising in substance misuse working as part of a multidisciplinary team. • All methadone is dispensed on site.

14. SatelliteClinics • Partnership between Health Service and Communities • Treatment Provided by Statutory Services • Members of a Multidisciplinary Team attend on a sessional basis. • Methadone Dispensed in Community Pharmacies • Prescribers: General Practitioners Specialized in Substance Misuse

15. Drug Treatment Center Board (DTCB) • Staffed by Consultant Psychiatrists and NCHDs • More difficult patients • Serious psychiatric illness • Serious behavioral issues • Amacus service • Temporary Transfer • Patients where no service available in area • Homelessness

16. Treatment Services • Other HSE areas provide treatment • Not adequate, patient transfer difficult • Prisons, treatment provided to • Those already in treatment • HIV positive • If agreed with HSE Addiction Services

17. Detox/ Abstinent Services Medical Supervision • Cuan Dara: six week programme also stabilisation programme especially for those pregnant • Keltoi: Post detox three months • Link with other agencies • Lantern • Cuan Mhuire • Coolmine • Simon Community (Alcohol Detox)

18. Treatment Provision • A protocol for the prescribing of Methadone in the community was set up in October 1998. • Treatment continues to be mainly centred in Dublin but has expanded to different areas of the country • Prior to the protocol most treatment services were provided in Central Services. • There were a number of untrained G.P.s prescribing for a large number of patients

19. Background • March 1993 • Department of Health and Children (DoHC) published a report on the establishment of a protocol for the prescribing of methadone • March 1995 • A pilot project for the implementation of the protocol was commenced • October 1998 • Protocol which had been signed into law in July was implemented

20. Protocol Objectives • To normalize patient attendance in community based services • To encourage G.P.s and Community Pharmacists to become involved in prescribing and dispensing methadone • To provide ongoing training and education for G.P.s and Pharmacists

21. Protocol Structure • Methadone is a controlled drug • Oral Methadone D.T.F 1mg/ml is the only available preparation • Specific Protocol Prescriptions issued • Treatment Cards provided for each client and held at the designated pharmacy

22. Treatment Card • Name and Address of Patient • Designated PH Number • Photograph • Name, Address and Tel of G.P and Pharmacist • Signature of Patient

24. Structure • National Central Treatment List Established • Confidential • Access only by doctors and pharmacists • Treatment is Free to all patients • Special Payments to G.P.s and Pharmacists

25. Structure • Level I G.P.s • Providing treatment for up to 15 stabilised patients • Level II G.P.s • Providing and/or initiating treatment for up to 35 less-stable patients • Maximum of 50 patients per practice • G.P. or Pharmacy • Appointment of GP Coordinator and Liaison Pharmacist

26. GP Coordinator and Liaison Pharmacist • Encourage Community G.P.s and Pharmacists to prescribe and dispense methadone • Initial and Ongoing Training and Education • Provide ongoing support and back up to community G.P.s

27. Overview of Protocol • Specialised Training for GPs and Pharmacists • Guidelines issued by Irish College of General Practitioners • Evidence based consistent with Eurometh Guidelines

28. On-Going Developments • On-Going Training for G.P.s and pharmacists • Continuous Liaison and back-up services provided by GP Coordinator and Liaison Pharmacist • Auditing of GP patient profile • Initiation of patients by G.P.s (Level II) • Transfer of stabilised patients to Level I G.P.s

29. Aim of Methadone Treatment • Reduce illegal heroin use • Improve Social stability • Reduce morbidity and death • Prevent transmission of blood borne viruses • Coincidently it reduces crime

30. Treatment Options - Medical Methadone Programmes • Detoxification associated with high relapse rates • Reduction Programme stabilisation and dose reduction over a period of six months or longer. • Maintenance Programmes The most evaluated treatment and probably the most successful • Counselling

31. Other Treatment Options • Buprenorphine Substitution treatment available for a feasibility study • Lofexidine Used in Detoxification programmes • Naltrexone Used Post detoxification

32. A blockade dose is the individual dose, which prevents : • Opioid abstinence syndrome including subjective symptoms of withdrawal as well as objective findings. • Reduction or elimination of drug hunger or craving. • The blockade of the euphoric effect of any illicitly self administered illegal drugs.

33. Blockade Dose • Blockade Dose is usually 80mg + 20mg. • Most patients blockade at 80mg. • Patients with a high tolerance 90mg – 120mg. • About 7% of patients require a higher dose.

34. Constipation Antitussive effect Myosis Increased bladder tone Overdose Blushing Itching Sweating Flushing. Prolonged QTc Respiratory depression Side Effects of methadone

35. Buprenorphine • Partial mu agonist • Less respiratory depression • Quicker safer induction • Cost • Street diversion ( injected )

36. PROBLEMS IN STABLE PATIENTS • Misuse of legally prescribed drugs • Use of illegal drugs • Alcohol • Increase in psychiatric illness • Pregnancy • Hepatitis C • HIV Infection

37. Other Illegal Drugs of Misuse • Cocaine • Ecstasy • Cannabis • Head Shop Substances • Methamphetamine

38. Cocaine • Cocaine is a powerful and addictive central nervous system stimulant • Use leads to euphoric state known as a “high” • Neurobiological studies suggest it taps into the brain reward system • Increased use since 1998 as a ‘street drug’

39. Peak Concentrations • Nasal inhalation - 5 to 20 minutes • Smoking: free based or as “crack” – seconds • Intravenous – seconds

40. Ecstasy • Use began in the late 1980s with the advent of the Rave culture and emerged as a problem in the 1990s. • Oral use, effects occur within 30 minutes can last for 4 hours. • Mood Change – Euphoric – Confident • “Crash”, severe lassitude and fatigue

41. Cannabis • Adolescent use can induce serious psychiatric illness • Affects concentration • Drop out • Do poorly in education • Gateway

42. Head Shops Still available, Mephadrone, BZP-derivatives, ‘Spice’, Skunk Under the counter Street Internet Hallucinogenic: Mescaline and LSA compounds Kratom opioid agonist Salvia Magic Mint Sida Cordifolia ephedrine Caffeine with Guarana 100 times more potent injected

43. Methamphetamine • U S Canada (Vancouver) • Eastern Europe Russia • Injecting culture • Meth Labs ( Mexico U S) • Pseudo ephedrine containing compound • Cough bottles (antihistamine)

44. Misuse of prescription medications • Benzodiazepines High rate of misuse in methadone maintained patient Misuse of Drugs Act 1993 Rohypnol, Temazepam. Report of Benzodiazapine Committee 2002 • Antidepressants Triptyzol, Prothiaden, Zispin • Antipsychotic medication olanzepine • Hypnotics Zimovane, Dalmane

45. Misuse of OTCs • Codeine • New Pharmaceutical Society Guidance Aug 2010 • Antihistamine • Cough Bottles

46. ALCOHOL • Most common ‘drug’ of misuse in Ireland • Gateway • Cross addiction is common • May revert to alcohol when opiate stable • Safe prescribing is necessary • Acamprosate (Campral EC), Disulfiram (Antabuse) • Detox Inpatient, Chlordiazepoxide (Librium)

47. HEALTH Poor health is common in this group of patients. • Lifestyle • Poverty • Immunosuppressive effect of opiates and cocaine.

48. Dual Diagnosis • Many with substance misuse have co-morbid psychiatric problems. • Increased level of symptoms in polydrug users. • Higher risk of suicides in this group of patients • Higher incidence of depression, some studies show 50% of opioid & cocaine users to report life time depression

49. Psychiatric Illness • Paranoia and Psychosis • Can be induced by ecstasy, cocaine, amphetamines • Personality Disorders

50. Pregnancy : Management • Prioritized access to treatment programmes • Stabilizing heroin addiction • Central Services • Maintaining stability • Prevents cycling effects of unstable drug use