Prescribing for young people

1. Prescribing for young people • What the literature has to say • hype’s prescribing process • hype young people’s experience

2. Prescribing for young people • Evidence • Criteria • Consent and competency • Aims of treatment • Principles of good practice • Prescribing • Assessment

3. hype Community Detox Service Information for referrers The above service was started in January 2003 for young people aged up to 18 who were looking for a rapid withdrawal with a view to abstinence. Referrals Criteria • Young people who have expressed a desire for a rapid detox from opiates. • Young people on 30mg or less of methadone. Exclusions • Medical or psychiatric history that would indicate community detox as a risk to physical or mental health. • Young people with a history of drug induced psychosis. • Young people with a current active alcohol dependence. • Young people with a history of violent or abusive behaviour towards staff. Referrals Process GPs:Referrals should be made in the usual way. It would be helpful if the referral letter was headed as a “Referral for Detox”. Agencies:Please complete the hype Community Detox Service Referral Form and either fax or mail it to us. Copies can be obtained from hype if you don’t already have one. Detox assessment We aim to offer appointments within a week of receipt of referral by the Detox Service. The Detox Assessment process would normally take 2-4 appointments over two weeks to complete. This will focus on exploring motivation for change, physical and mental fitness and the social supports available to the young person. There will also be an exploration of previous detox experiences and the reasons behind relapses. This will help the young person to use these experiences as useful learning tools in identifying areas of vulnerability to relapse and promote self-awareness in relation to their addiction recovery. Preparation From the information gathered at the assessment stage, ways in which to best support the detox process will be identified with the patient. This process will include palliative care to minimise physical withdrawals, ways in which to self-monitor and looking at identifying relapse cues and triggers.

4. Strategies for cues and trigger avoidance will be discussed. The emphasis will be on the young person taking responsibility for the detox by way of exercises designed to promote cognitive restructuring and self-awareness. Practicalities such as medication regimes and appointments will also be organised at this time. Supporting relatives or others will have the opportunity to be included at this stage, with the young person’s consent, for advice and support regarding their role in the detox. Detox The detox method will be identified with the young person at the detox assessment stage and although medication regimes may differ, the level of psychosocial support is the same. The young person will be seen daily for the first two weeks (excluding Saturday and Sunday). Advice and support will be offered throughout on the management and monitoring of withdrawal symptoms, as well as continued focus on relapse prevention. The young person will be encouraged to refer to the strategies identified in the assessment and planning stages to help with cravings and cue/trigger avoidance. The effectiveness of these will be monitored. Staff will liaise with relevant medical colleagues regarding any adjustments to medication regimes and random urine testing will be carried out to monitor detox authenticity. Relapse prevention The young person will be offered the opportunity to commence opiate blocking medication to protect their abstinence. The consumption of this medication should be supervised by a supportive other and in order for this to begin, the young person must remain opiate free for a minimum of seven days. In addition, the young person will be offered time limited individual relapse prevention sessions. This will be for ten sessions, one per week, each focusing on a particular aspect and addressing difficulties as they arise. Follow Up/ aftercare Many young people wish to cut their link with drug services following detox or relapse prevention and as part of the discharge process the need for ongoing support will be assessed on an individual basis. Referral either back to another worker within hype or to other agencies will be made with the young person’s consent. Those who do not wish any further support will at this point be discharged from the service. All enquiries are welcome and should be made to: Jayne Reed Senior Community Mental Health Nurse Tel: 0131 466 4607 Hype Fax: 0131 466 4604

5. hype Community Detox Service Referral Form Date _________________ Referrer __________________ Name _________________ Address __________________ DOB _________________ GP ______________________ Drugs Used: Include Alcohol _____________________________________ Current Pattern of Use ___________________________________________ Drug Use History Age Drug Amount Frequency Route Still Using History of Mental Health Age Problem Diagnosis Treatment Where Outcome Ongoing? History of Medical Problems Age Problem Diagnosis Treatment where Outcome Ongoing?

6. Social Situation/Environment Current accommodation ______________________________ Accommodation problems ____________________________ Proximity to drug using circle _________________________ Current education/work status _________________________ Non drug using supportive/significant others Name Relationship Length known Addictions? Support detox? History of previous detoxes Age Where Method Outcome Days drug free Relapse trigger Motivating factors in previous detoxes 1 2 3 Motivating factors for this detox • 2 3 Any other relevant information

7. hype Community Detox Service Self-Assessment (please complete and bring to appointment) Name__________________________________ How long have you been drug dependent? __________________________________ Have you ever detoxed before? Yes/No (if no, go to page 3 How many detox attempts?_____________________________________________ When were these? (give month and year) __________________________________ Why did you choose to detox on these occasions? ___________________________ Where did you detox? _________________________________________________ Did you take any medication to help with detoxing? _________________________ Please state what:_____________________________________________________ How long did your detox (es) last? ________________________________________ Did you become opiate free? _____________________________________________ What is the longest you have been free of drugs?_____________________________ Who or what were supporting you through detox/abstinence?___________________ What have you learned about your addiction from your previous detox/ abstinence experiences? _________________________

8. Relapse What led to your relapse(s)? Please circle all that apply. Cravings Depression Feeling stressed Life pressures Boredom Lack of support Anxiety Family relationships Feeling isolated Prison Couldn’t tolerate withdrawals Being offered drugs Realise didn’t want to stop Didn’t know how to cope drug free Other (please state) Previous withdrawal experience What withdrawal symptoms have you had before? ____________________ Was there any symptom you found too difficult to cope with? ___________ This detox Why do you want to consider opiate detox now? _____________________ Are you taking any other drugs (including cannabis or alcohol)? Yes/No If yes, what and how much do you take every day? ___________________ Are they prescribed? Yes/No. If yes, who prescribes? ______________ Are there any other drugs including cannabis and alcohol that you could not do without? Yes/No. If yes, what? _____________________________ Will you continue to take other drugs during your detox? Yes/No If yes, what? _______________________________________________ Do you want to be opiate free by a particular date? Yes/No. If yes, when and why? Social Circumstances Do you have children? Yes/No. If yes, Name Age Gender Main carer Do you have anyone living with you who depend on you to look after him or her? Yes/No. If yes, state who and your relationship ________ __________________________________________________

9. hype Community Detox Service Substance Use Diary Name ______________ Week Beginning _______________________ Day What & How much Where, when & Why did you use? did you take who with Physical Emotional

10. hype Prescribing Service Vital Sign & Opiate Withdrawals Monitor Name ___________________________________ Date Time Signs Insomnia Sweating Hot/Cold Yawning Diarrhoea Rhinorrhoea Sedation Elation Vomiting Anorexia Pilo-erection Drug seeking Restless Agitation Lacrimation Observations Blood Pressure MmHg Pulse BPM Pupil Size Assessed by __________________________________________________________ Scores 0 – absent 1 – not sure 2 – mild 3 –moderate 4 - serve

11. hype Community Detox Service Decisional Balance Name ____________________________ What was/is good about current What was/is bad about drug use? Current drug use? What would be good about not What would you miss Using opiates? About opiates?

12. hype Community Detox Service Home Environment Assessment Name: ____________________________ Availability of supporter Attitude of supporter Always available 0 Very supportive 0 Often available 1 Supportive 1 Sometimes available 2 Slightly supportive 2 Never available 3 Not supportive 3 Commitment of supporter Level of noise Very committee d 0Tranquil 0 Committed 1 Reasonably quiet 1 Slightly committed 2 Noisy 2 Not committed 3 Very noisy 3 Space to be alone Presence of young children/pets Ample room 0 Nochildren or pets 0 Some room 1 Sometimes present 1 Little room2 Always present 2 None 3 Presence is disruptive3 General Atmosphere Presence of other substance users Very organised 0 Never present0 Organised 1 Sometimes present 1 Slightly disorganised 2 Often present 2 Disorganised 3 Always present 3 Areas for Care Planning Score______________

13. hype Prescribing Service Treatment Aims Name ________________________ Treatment Aim Review Date Young Person Date Nurse Date

14. hype Community Detox Service Suitability Assessment Young person’s name_________________________ Date of birth __________________ Self Assessment completed and returned? Yes/No Decisional Balance completed and returned? Yes/No Substance Use Diary completed and returned? Yes/No Does the young person wish to consider lofexadine? Yes/No Baseline pulse: _________bpm BP.: __________mmHg Date and results of last urine screen:_____________________________ Health Is there any physical/mental health history? Physical: Mental: Medical Responsibility Who is prescribing for detox? Date prescription written Date GP informed

15. hype Community Detox Service Contract for Community Detox Name_________________ For opiate Community Detoxification to take place safely, there are certain conditions, which we expect you to follow. 1. You agree that the responsibility for any medication prescribed is yours. 2. You agree not to take opiate drugs (except those, which you are legitimately prescribed,) throughout the detoxification process. 3. You agree to be randomly tested for drugs. 4.You agree not to be physically or verbally abusive to staff. 5. You agree to attend all arranged appointments. Failure to comply with any of the above may lead to your community detox being stopped. Please sign here to show that you fully understand and are in agreement with this consent form. Young Person_________________________ Date_________ Nurse______________________________Date_________

16. hype Community Detox Service Date________ Dear Dr_________ Re opiate detox for name dob address . I am writing to let you know that ____________ has completed their detox from opiates. I will continue to see them for ten weeks relapse prevention. I will write and inform you of their progress following this piece of work. As you have previously agreed to prescribe Naltrexone for _____________, please arrange for a prescription of Nalorex, __mg daily to be available for collection from your surgery on ________. Yours Sincerely Jayne Reed Senior Community Mental Health Nurse

17. Jayne Reed, Senior Community Mental Health Nurse Certificate of Achievement hype is hereby granted to: ………………….. to certify that you have tested negative for opiates Well Done! Granted: (date)

18. Prescribing review • Why were you referred to hype? • Why did you need a prescription? • What are you prescribed? • How has your prescription helped you? • Are there any negative effects of receiving a prescription? • How would your life be different if you hadn’t received a prescription? • Is there anything that could have been done differently?

19. Why were you referred to hype? • “Because I was using opiates (smack)” • “I had a bad heroin problem at a very young age” • “I just wanted to come off and the doctor told me to come to hype for help because hype specialises in this help” • “I referred myself cause I wanted to get off heroin as it was no life” • “Spoke to my social worker about being on kit. Told him I had been before for hash. He organised a meeting” • “My mum’s support worker thought it might be good for me. That was the first time I really spoke about my drug problem”

20. Why did you need a prescription? • “Because I had a habit. I wanted to come off. It’s hard though, it’s really addictive” • “Cause I wasn’t strong enough to do it on my own. I tried to go cold turkey with my mum and dad but it didn’t work” • “To help me come off street drugs. To stabilise me. That’s me probably contradicting myself as I’ve used on top” • “I wanted 2 come off heroin without withdrawing so I was prescribed methadone and it made me feel normal or ok” • At first I didn’t think I needed one. I changed my mind – It feels cleaner than heroin & it feels like I’m more supported, friends, family, even the chemist”

21. What are you prescribed? • “30mls methadone” • “85mg methadone” • “32mls methadone (currently on a 3ml per week reduction from 70mls)” • “At the moment in time I’m prescribed 8 yellow valleys (diazepam) each day and 30mls of methadone” • “40mls methadone” • “30mls methadone” • “80 mls methadone”

22. How has your prescription helped you?(both physically and in other areas of your life) • “Stopped me from withdrawing. I’d probably be at rock bottom, probably dead” • “It has kept me off the heroin for the last 2 years” • “It has helped me with my baby boy. Being clean and drug free for him. So all my attention is focussed on him. You counsel us as well, it’s not just the prescription” • “Physically I can get up out of my bed without rattling and I can do what I want to do all day without running around trying to get smack” • “My prescription helped with family because I wasn’t taking heroin, just my medication” • Don’t feel weighed down worrying about money, heroin or health. Able to cope better”

23. Are there any negative effects of receiving a prescription? • “You do not want to have to take methadone every morning but in my case I have to or I will be very ill” • “Nope” • “Being supervised at the chemist, I bumped into my old best friend and it was embarrassing” • “My teeth are rotting. I feel funny going into the chemist everyday as they all know – it’s a wee bit embarrassing” • “I guess sometimes you wish you didn't have to go to the chemist every day, feels quite a tie but when I think about before I prefer this to before”

24. How would your life be different if you hadn’t received a prescription? • “Looking really unhealthy and skinny, looking 4 times as worse as before I went into secure” • “I would probably be in the jail (stealing to get money for heroin)” • “Probably wouldn’t have my baby girl – cause you helped me when I was pregnant. I probably would’ve had to have an abortion” • “I moved house recently – only did 3 trips. Moving in was 20 trips but sold all my stuff” • “I probably wouldn’t be here to answer that if it wasn’t for the staff” • “I probably wouldn’t have fallen pregnant and I probably would’ve had him taken off me as well” (on C P register)

25. What do you think about the assessment process for prescribing? • “I liked doing the drug diaries” • Thought it was quite long. Asked me questions that I hadn’t thought of before. Gave me a wake up call” • “Alright. Planning each day was over the top” (during detox) *dad disagreed! • “It was a nightmare – to be honest, just because you expect it straight away” • “The hardest bit was coming in withdrawing to see the doctor” • It was stressful but I was feeling happy at the same time because I was getting a prescription” • “I think they are doing the right things, always have”

26. Is there anything that could have been done differently? • No and I’m glad it has been done this way because I still have my life at the moment thanks to the doctor and nurse but we are still working together to sort this very weird problem out as quickly as possible” • “I don’t like my chemist at all but nothing else” • “You do everything okay” • No. Not that I can think of”

27. Is there anything that could have been done differently? • “I always wanted dihydrocodeine and diazepam as I thought they would be easier to come off. I think I was a bit young for methadone. I now think I should’ve tried Subutex. I think folk should try that first” • “When I was on the detox, I had to come up every day and get checked every day. I would rather have stayed in my bed” • “Not really, everything here was fine. Maybe I could have done things a little differently but I didn’t. I could’ve stuck to my prescription and not taken smack - don’t think I was ready it wasn’t the right time”

28. References • Crome IB, Christian J & Green C (2000) A unique designated community service for adolescents: policy, prevention and education implications. Drugs Education, Prevention and Policy. 7, 87-108. • Crome IB (2004) Treatment. In Young People and Substance Misuse. (eds Crome IB, Ghodse H, Gilvarry et al). London: Gaskell • Department of Health (1999) Guidelines on Clinical Management: Drug Misuse and Dependence. Norwich:The Stationery Office. • Health Advisory Service (2001) The Substance of Young Needs. London: Drugs Prevention Advisory Service, Home Office. • Stewart DG & Brown S (1995) Withdrawal and dependency symptoms among adolescent alcohol and drug abusers. Addiction. 90, 627-635.