UK Treatment and Prevention Strategies

1. 1 UK Treatment and Prevention Strategies Current Debates and Directions Dr Alex Baldacchino October 2002

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5. 5 (1) What is treatment? Objectives, Philosophies, Principles of Treatment Addictions & its theories

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20. 20 (2) Who is treated? The client/patient Dependencies Problem drug use Experimental use

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25. 25 (3) How is treatment delivered?

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31. 31 Treatment Effectiveness In Drug Misuse UK Perspectives

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46. 46 In Opioid Dependent Individuals Predictors for successful treatment with heroin users: Length of treatment episode > 90 days & longer duration Non-injector status Reduced severity of drug and alcohol use prior to admission Absence of major psychiatric history Family support, unemployment, social stability Criminal background, compulsory treatment supervision

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60. 60 Recommendations for drug treatment service managers Participate in their local Action on Waiting Group Work with commissioners to be clear about their role/remit in the local treatment system, including their service specifications and client work Ensure that information about their services is accurate and reflects local diversity Develop locally agreed screening and assessment criteria and procedures with other providers and their joint commissioners, as in sixth point above

61. 61 Review their appointment system and implement strategies to optimise attendance; service users should be involved in this Retain contact with clients waiting for structured treatment, to manage harm and build motivation Ensure all structured treatment is care planned and delivered as per recognised standards (Quads 1999, clinical governance and Guidelines for the management of dependent substance users in Fife)

62. 62 Promote managed movement through treatment, including planned discharge Develop protocols for clients who default, inc interventions to prevent drug-related deaths Manage workforce constraints by ensuring that administrative and clinical staff and managers focus on their own specialist roles and responsibilities Ensure mechanisms for evidence-based practice

63. 63 1. Map local services DAAT should comprehensively map the full range, role and client groups served by all local providers. The exercise should include treatment services, primary-care services involved in treatment and generic providers of care services.

64. 64 2. Develop a local contingency plan Addiction Services and other groups should develop this - with the involvement of Tier 2, primary-care, LHCC and A & E services - to manage sudden change in the nature and size of demand for treatment

65. 65 3. Forecast demand and supply DAAT and LHCC should do this as part of needs assessment, and identify possible impact on the treatment system, informing investment.

66. 66 4. Establish joint commissioning arrangements DAAT should assign responsibility/influence for funding to a joint commissioning manager or lead commissioner. This should include overview responsibilities for mainstream funding and the pooled budget

67. 67 5. Provide information on available services to cut inappropriate referrals Providers already do this but they and DAAT should review the quality of information about local services once mapping is complete

68. 68 6. Develop common assessment criteria Providers should also implement Models of Care triage assessment. The Fife Addiction Services Assessment Tool (FASAT) and others

69. 69 7. Streamline reassessments When a client/patient is re-referred or wants to be re-admitted, reassessment must not duplicate existing client information

70. 70 8. Keep case review focused Providers must include case reviews in care planning and management, and deliver them quickly, particularly to GPs in shared care. They must not incur unnecessary reassessment

71. 71 9. Establish criteria for prioritising clients LHCC/Trust (Fife wide based ) or other more localised groups should do this based on locally agreed protocols to assess risk. Protocols should state possible risks, such as overdose, and the people, behaviours and circumstances which take priority. The groups must consult and advise referring generic services of these priorities.

72. 72 10. Work with general practitioners and general hospitals to develop local protocol Addiction related groups and local practices and/or local general hospitals should jointly develop a local protocol for managing drug users on their practices (or LHCC basis) and/or general medical and surgical wards

73. 73 11. Conduct an appointments audit Providers must identify patterns in unattended appointments by clients and services and consult clients on improvements

74. 74 12. Maintain contact with clients on waiting lists Service providers should do this to identify changing need and provide interim support to reduce risk

75. 75 13. Enhance motivation of clients on waiting lists Providers should work with waiting clients to improve retention and effectiveness of treatment

76. 76 14. Consider subcontracting elements of service With joint commissioners, providers should consider joint appointments or inter-service seconding of staff

77. 77 15. Manage workforce constraints Again in consultation with joint commissioners, providers should separate administrative and clinical caseloads and consider initiatives such as nurse consultants

78. 78 16. Develop evidence-based practice Providers must keep updated about emerging evidence and standards, offer staff relevant professional journals, develop monitoring systems and implement standards

79. 79 17. Establish and maintain clinical governance systems NHS providers should meet standards and ensure their systems interface with relevant others. Only clinically governed services should be purchased

80. 80 18. Produce individual care plans with goals Reviewed with clients and partners, these should be based on short-, medium- and longer-term goals

81. 81 19. Develop discharge plans and create a system of movement from specialised to generic services. Providers should include a provisional discharge date in the care plan

82. 82 20. Develop clear protocols for clients who default Including helping clients to solve difficulties, involving colleagues and other agencies, and carrying out an audit of clients who are discharged early

83. 83 21. Develop shared care with GPs This should work in partnership with Primary Care Trusts and with the Substance Misuse Management in General Practice projects to achieve this There are different levels of shared care. The Kennoway style, The GP Specialist style and the St Andrew’s style

84. 84 22. Develop shared care for through- and after-care Treatment specialists should regard generic providers as part of the extended care team. The rehabilitation strategy in Fife is to move people from treatment to a psychosocial approach (1st and 2nd level rehabilitation)

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90. 90 Harm Reduction Centre

91. 91 Aims and Objectives To minimise the transmission of HIV, Hepatitis B and C and other blood borne viruses among injecting drug users and their sexual partners by reducing the percentage of drug users who report sharing injecting equipment. Improve access to health and related services.

92. 92 Aims and Objectives To protect members of the population from the risks associated with the presence of used injecting equipment in public places. To make contact with injecting drug users who are not in contact with drug services. To be able to respond to changing patterns in drug misuse. To ensure effective and reliable provision of needle/syringe exchange schemes at participating community pharmacies and other static sites/community outlets across Fife.

93. 93 Aims and Objectives To provide written information about transmission of HIV and blood borne viruses, safer sex and safer drug use. To provide information about agencies that offer confidential counseling and advice on drug use and HIV infection. To provide training and support to all staff involved in the exchange scheme.

94. 94 Community Drug Team (CDT)Assessment & Treatment Team

95. 95 Aims & Objectives Undertake comprehensive assessment of clients referred to the CDT. Utilising the “Guidelines for the Management of Dependent Substance Users in Fife”, offer a variety of interventions to meet client need. In conjunction with the client develop, implement and evaluate action plans which are realistic, evidenced based and prioritised.

96. 96 Aims & Objectives Agree reduction regimes and monitor prescribing regimes when appropriate. To offer home detoxification, using a range of prescribing options to appropriate clients. Promote the shared care model by regular communication with GPs and other professionals. Identify appropriate pathways for clients and carry out internal and external referral.

97. 97 Interventions Pharmacological Methadone titration- short term stabilisation Detoxification (tolerance testing if required). Methadone longer term stabilisation. Buprenorphine detoxification. Lofexidine detoxification. Naltrexone – post opiate detoxification. Diazepam detoxification. Regular/random urinalysis.

98. 98 Interventions Psychological Motivational Interviewing - (FRAMES – feedback, responsibility, action, menu, empathy, self-efficacy). Cognitive Behaviour Therapy Relapse prevention Psychiatric assessments by Consultant Psychiatrist (if required) Counselling skills Psychologist input

99. 99 Tolerance Testing Aim To determine a dosage of Methadone which will comfortably relieve and prevent withdrawal symptoms without producing sedation. Criteria The client is Methadone naïve. The client has increased opiate tolerance requiring higher dose of Methadone. The stability of the client’s drug use cannot be confirmed.

100. 100 Community Drug TeamCare Management

101. 101 Criteria for Care Management Stable on their prescribed medication or be drug free Have identified goals which they are prepared to work towards

102. 102 Forensic Drug Treatment Team

103. 103 Forensic Issues Drug Treatment & Testing Orders (D.T.T.O.) Drug Court (Probation With Condition of Treatment)

104. 104 Addictions Nurse Interventions Assessment Drug Substitution Tolerance Testing Motivational Enhancement Relapse Prevention Solution Focused Therapy Urinalysis

105. 105 Community Alcohol Team (CAT)

106. 106 Role of CAT To promote a shared care model within the Primary Care setting. To assess, plan, implement and evaluate individualised care. To safely withdraw people from alcohol using the Chlordiazepoxide Reduction Protocol.

107. 107 Role of CAT To provide client centred, focused intervention post detox to reduce the risk of relapse and maintain motivation. To identify appropriate follow up care in conjunction with the client and refer to other agencies accordingly. To provide a high level of relevant communication to referrers.

108. 108 Role of CAT To provide specialist alcohol information to local statutory/non statutory agencies.