SPECIALIST COMMUNITY ADDICTION SERVICE

1. SPECIALIST COMMUNITYADDICTION SERVICE Services for drug users throughout Oxfordshire Jill Lark RGN Addiction Nurse Specialist SCAS

2. AREAS TO BE COVERED Introduction Who's Who? Terminology Different Drugs Clinical Management Drug Paraphernalia Other Services Vignettes

3. WHO AM I? RGN 22 years � trained in Oxford ICU & angiography Transplantation New Zealand - Private United Kingdom - NHS Addictions Diploma St Georges 7 Years Addictions (including 5 years homeless network)?

4. WHOSE WHO National Treatment Agency Drug & Alcohol Action Team Specialist Community Addiction Service Shared Care (DAAT + PCT)?

5. WHAT IS SHARED CARE? Shared Care Model promotes the shared clinical care of a patient by the GP or GpwSI, SCAS Nurse & Pharmacist which will usually involve substitute prescribing of either methadone or Subutex

6. THE AIM OF SHARED CARE The principle aim of shared care in the clinical context, is to provide a comprehensive service to drug users that will reduce drug related harm and the potential for death.

7. OBJECTIVES OF SHARED CARE Accessible & consistent service Promote best practice Develop good working relationships Provide consistent code of practice for prescribing and management Provide care for the majority of drug users

8. WHY SHARED CARE? �Medical Practitioners should not prescribe in isolation, but should seek to liaise with other professionals who will be able to help with factors contributing to a individual's drug misuse.� DoH 1999

9. WHO IS SHARED CARE? General Practitioners GP's with a Special Interest (GPwSI)? SCAS Nurses Community Pharmacists

10. CITY CENTRE v COUNTY Consultant Dr Andrew McBride Clinical Nurse Lead Sam Clarke 07788754345 11 GP surgeries Consultant Dr Gail Critchlow Clinical Nurse Lead Mark Stevens 07788754352 15 GPs 4 Resource Centres Abingdon, Didcot, Witney & Bicester

11. WHY PRESCRIBE? Engage patient in treatment Reduce or prevent withdrawal Reduce criminal activity Reduce unsafe sexual practices Reduce dependence on drug using lifestyle Opportunity to stabilise drug intake Reduce unsafe injecting practice/BBV

12. BENEFITS OF PRESCRIBING IN PRIMARY CARE Treatment accessible & relevant Recognises multi-factorial nature of drug use ? Minimises the risks of isolated practitioners Cost effective Patients treated in normal primary care setting

13. REASONS WHY PEOPLE START Mental Health Problems Life Crisis Abuse/care system Boredom Women - partners STOP Age � life begins at 30 Rock Bottom Physical Crisis Boredom Never

14. THE CYCLE OF CHANGE Ambivalence Contemplation Action Maintenance Relapse Prochaska & DiClemente

15. ADDICTION v DEPENDENCE Crime Social isolation/family rejection Reduced self care/nutrition Reduced sleep/reduced mood Unemployment Chaos BBV & DVT etc Mental Health problems Increased risk of self harm Physical and psychological

16. THE JOURNEY THROUGH ADDICTION Titrate Stabilise Maintain Reduce Detox Rehabilitation Recovery

17. HEROINSIGNS OF USE Pinpoint pupils Droopy eyelids Relaxed state Gouching Reduced cough reflex Reduced heart rate Lethargy Itching Reduced libido Needle marks Abscesses in strange places DVT Hooded Sweatshirts

18. HEROINSIGNS OF WITHDRAWAL Dilated Pupils Runny Nose/Eyes Yawning Nausea & Diarrhoea Muscle Aches & Cramps Goose Bumps/Shivering Sweating

19. ASSESSMENT TEST URINE � NON NEGOTIABLE Withdrawal Signs Current usage Duration of Use Track Marks Alcohol Poly drug use Psychiatric History Physical Health Past Treatment Social Factors Weigh Them

20. INJECTING EQUIPMENT 2ml Plastic water ampoules are prescription only so packs only give glass ones 1ml syringe barrel will put less pressure on the vein, but some people will only use 2ml (especially groin injectors) because it will �ruin their buzz� otherwise. Don�t underestimate the power and importance of the ritual of preparing etc. for drug users. Vitamin C is usually used with heroin as it is less acidic and therefore less damaging on the veins.

21. METHADONE v SUBUTEX More than $30 Daily Injecting Established habit Polydrug use Chaotic Less than $30 Daily Smoking Short habit Heroin only Stable

22. Substitute Prescribing Methadone needs to be prescribed safely to avoid the dangers of overdose and diversion STARTING METHADONE IS NEVER AN EMERGENCY Starting methadone without evidence of opiate dependency is very dangerous & should never be done.

23. INITIATING METHADONE TREATMENT Methadone Mixture 1mg/ml (Not 5mg/1ml)? FP10 Blue Prescriptions Never Physeptone Tablets or IV Ampoules Daily supervised consumption (12 weeks)? START LOW & GO SLOW First 2 weeks greatest risk of overdose

24. INITIATING SUBUTEX TREATMENT 8 hours after last dose of heroin 24-36 hours after last dose of methadone moderate signs of withdrawals Daily Supervised Consumption FP10 Not licensed for use in pregnancy

25. NALTREXONE When urine clean of ALL opiates Check LFTs before & throughout treatment Starting dose 25mg daily increasing to 50mg Double dose and take thrice weekly Expensive 50 tablets = $90 Naltrexone implants are NOT licensed

26. CRACK COCAINE(white, stone, rock)? Cocaine � pure, expensive, snorted Freebase � street cocaine that has been converted to a pure base by removing the hydrochloride salt & many of the adulterants (talc,flour). End product is not water soluble and as such can only be smoked. Crack � powdered cocaine melted with water. When liquid cools it is mixed with baking soda and cold water and then cut into small pieces which harden and �crackle� when smoked

27. CRACKSIGNS OF USE Increased Energy/Fast Speech/ Fidgety/Increased Libido Euphoria Weight Loss Bad Breath/Frequent licking of lips Anxiety/Paranoia Birth Defects  Insomnia Respiratory Problems/Runny nose/colds/chronic nasal problems Scabs/abscesses Depression/Mood Swings Tachycardia/MI

28. TREATMENT OF CRACK USE Triggers Cravings Relapse Prevention Auricular Acupuncture Reflexology Classical music! Libra (Cranstoun)? Group Work 1:1 Work

29. PREPARING CRACK Washing cocaine hydrochloride with sodium bicarbonate = good for IV use Washing the cocaine hydrochloride with ammonia = produces crack cocaine. This has a better affinity with the lungs so better for smoking.

30. CRACK USE Citric acid is generally better for crack use. There are lots of problems associated with crack use. Local anaesthetic, Smoking crack � dehydration, - cracked lips, - BBV Can use, beer tin, Lucozade bottle. Will also need, gum, biro, silver foil and elastic band.

31. BEFORE & AFTER

32. BENZODIAZEPINESTHE POSITIVES Highly effective in the short term Rapid onset of action

33. BENZODIAZEPINES THE NEGATIVES Tolerance & dependency develop quickly HUGE street value = Diversion Rebound anxiety/insomnia Withdrawal symptoms & fits Increases affects of alcohol, methadone & heroin Risky in overdose Increased drug hunger/BBV/UPSI Poor social functioning

34. BENZODIAZEPINEWITHDRAWAL SYMPTOMS Cravings, perceptual distortion,phobias Anxiety,panic attack, poor concentration Crawling skin Ataxia/tremor Hypersensitivity to light,smell, touch, taste Dry mouth Diarrhoea,constipation Flushing,racing pulse,sweating, Thirst, frequency, incontinence Insomnia

35. BENZO REDUCTION Convert all benzos to equivalent dose of diazepam Make all changes at the same time Diazepam 10mg is = to Temazepam 20mg Nitrazepam 10 Lorazepam 1mg Oxazepam 20mg Chlordiazepoxide 20mg Rohypnol 1mg

36. BENZODIAZEPINESIN SUMMARY Not Licensed for opiate withdrawal Avoid or refer to SCAS psychiatrists Potentiates the affects of alcohol,heroin,methadone Liquid Form only Daily Supervised Consumption on FP10 form

37. BENZODIAZEPINE OBNOXIOUSNESS RATING EVALUATION 10mg � �Just for a few days doc� 30mg - �But I really need them� 60mg - �You CANT stop them!� 100mg � �What day is it?� 200mg � Patient looks like a sleeping horse 300mg � �I woke up at the police station having tried to steal a freezer from Comet�

38. BORE IN ACTION

39. DONT ENABLE THEIR CHAOS

40. IF YOU'RE WORKING HARDER THAN YOUR PATIENT, THERE'S SOMETHING WRONG

41. Approximate drug detection times in urine Heroin Methadone Codeine Dihydrocodeine Cocaine Benzodiazepines Cannabis (acute)? Cannabis (chronic)? Ectasy Subutex Alcohol 1-3 days 1-2 days 2-3 days 4-5 days 12 hours � 3 days 1 day- 3 weeks 2-7 days Up to 30 days 2-4 days 2-3 days 12-24 hours

42. EVOLVE 10-18 year olds Community support Living with Oxfordshire Problematic & high risk use Access to substitute prescribing or community detox Screening & advice BBV's Auricular acupuncture enquiries@EvolveOxon.co.uk 01865 723909

43. ALCOHOL DETOX CDZ 10 day community based treatment Alcoholics Anonymous Libra 1:1 Alcohol Counselling OR 1 Day Symptom Triggered Detox

44. THE MORNING AFTER

45. CRIMINAL JUSTICE SERVICES Probation HMP Bullingdon CARAT DIP DRIP SMART AARS

46. MENTAL HEALTH SERVICES OBMH CMHT Warneford Littlemore Forensic Services Complex Needs Crisis Intervention Team Assertive Outreach Team Elder Stubbs Restore & Beehive Elmore Team Mind Group Services Mill Acorn Gemini

47. HEALTH SERVICES A & E Health Visitors Practice Nurses District Nurses Social Workers Hepatology Dept Harrison Dept John Warin Ward Barnes Unit

48. HOUSING SERVICES Street Services Team O'Hanlon House Lucy Faithful House Simon House The Bridge Julian Housing Stonham Housing Mind Housing Response Housing

49. DAY SERVICES Wet Room Day Centre The Gap The Gatehouse Baseline Libra 1:1 SMART Counselling Womens' Service