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

2. DEVON DRUG SERVICE Partnership between DPT & EDP 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. DEVON DRUG SERVICE Partnership between DPT & EDP Tier 3 Services GP-led substitute prescribing (“shared care”) Specialist substitute prescribing & detoxification Psychosocial interventions (1:1 & group-drug workers)

4. DEVON DRUG SERVICE Partnership between DPT & EDP Tier 3 Delivery Staff Care co-ordinator Support Worker & GP Service User DDS Support Worker Care Co- ordinator GP

5. DEVON DRUG SERVICE Partnership between DPT & EDP 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. DEVON DRUG SERVICE Partnership between DPT & EDP Primary Care (GP) Prescribing Engage more GPs with primary care prescribing Emphasis on throughput & needs-led treatment Strengthened governance in shared care

7. DEVON DRUG SERVICE Partnership between DPT & EDP Shared Care Care coordinated intervention to include prescribing intervention and psychosocial package of support. 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 Preparation for Residential Rehab Client reviewed on a regular basis by care coordinator and support worker. Drug screened and risk assessed. Client stabilised meets criteria for shared care. Client fails to stabilise – review and consider Low Threshold prescribing. Review if client requires prescribing intervention. Discharged Successful discharge client ends treatment. Client destabilises transfer to specialist prescriber until stabilised. Complicated - complete prescribing needs or risk management issues requiring ongoing specialist prescribing intervention. Reviewed Treatment Options Pathway for Service Users Requiring Prescribing Intervention Triage Assess Comprehensive Assessment

8. DEVON DRUG SERVICE Partnership between DPT & EDP ICP Shared Care evolving 2010-13 Triage assessment Allocation to Care Coordinator (CC) Starts care plan Liaises with GP to agree shared care CC coordinates Prescribing assessments

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

10. DEVON DRUG SERVICE Partnership between DPT & EDP 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. DEVON DRUG SERVICE Partnership between DPT & EDP Pharmacy collection Supervised consumption for3/12 Pharmacy reports non- collection & CC checks monthly >3 non-collection CC holds PX contacts SU to check not too intoxicated to collect >5 non-collection GP to re- titrate dose

12. DEVON DRUG SERVICE Partnership between DPT & EDP 3 monthly 3 way meeting GP/CC/SU SU=Service User Stablisation For ~6-12 months Unstable DOH guidance More intense psychosocial review Px

13. DEVON DRUG SERVICE Partnership between DPT & EDP Total destabilisation after re-titrations or other reasons Check motivation Suitability for Tier 3 Further secondary care review Or low threshold Px

14. DEVON DRUG SERVICE Partnership between DPT & EDP 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

15. DEVON DRUG SERVICE Partnership between DPT & EDP Chapter 2 Clinical Governance  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

16. DEVON DRUG SERVICE Partnership between DPT & EDP 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

17. DEVON DRUG SERVICE Partnership between DPT & EDP Recovery Model Psychosocial Program assists graduated reduction if stable Relapse Prevention & SU life recovery

18. DEVON DRUG SERVICE Partnership between DPT & EDP 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

19. DEVON DRUG SERVICE Partnership between DPT & EDP 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

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23. DEVON DRUG SERVICE Partnership between DPT & EDP 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)

24. DEVON DRUG SERVICE Partnership between DPT & EDP 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

25. DEVON DRUG SERVICE Partnership between DPT & EDP Gp is the long-term therapist in terms of empathy

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28. DEVON DRUG SERVICE Partnership between DPT & EDP 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

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30. DEVON DRUG SERVICE Partnership between DPT & EDP 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

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32. DEVON DRUG SERVICE Partnership between DPT & EDP Any Questions?