1. Focus on Addictions and Homelessness Catriona Ritchie NHSGGC Addictions Services GP ST 1+2 Teaching – Deprivation Related Problems in General Practice 18 th June 2013

2. Intended learning outcomes Concepts of addiction Concepts of homelessness The role of health care The role of GP STs

3. Concepts of addiction Models of addiction –disease, psychodynamic, temperance, genetic, cultural, biopsychosocial Defining addiction Recovery

4. Harmful / Hazardous use or Dependency? A strong desire or sense of compulsion to take the substance; Difficulties in controlling substance-taking behaviour A physiological withdrawal state Evidence of tolerance Progressive neglect of alternative pleasures or interests Persisting with substance use despite clear evidence of harm

5. What is recovery? A process through which an individual is enabled to move from their problem drug use, towards a drug-free lifestyle as an active and contributing member of society... recovery is most effective when service users’ needs and aspirations are placed at the centre of their care and treatment…an aspirational and person-centred process. 2008 Scottish Government

6. What is recovery? The 2010 UK Drug Strategy notes that recovery: involves three overarching principles– wellbeing, citizenship, and freedom from dependence...It is an individual, person- centred journey, as opposed to an end state, and one that will mean different things to different people.

7. Recovery Journey metaphor Chronic relapsing condition Harm reduction or abstinence Recovery capital Recovery focussed care

8. Homelessness The concept of homelessness has broader connotations, for “home” has both physical and psychological meanings. A home provides roots, identity, security...a place where warmth and emotional wellbeing are normally found.

9. Role of health care Therapeutic alliance Evidence based interventions Managing mental health co-morbidities Managing physical health co-morbidities Safeguarding children

10. Non-pharmacological interventions Named key worker Develop, implement and monitor care plan Interventions to reduce harm –Needle exchange, safer injecting, naloxone Psychological interventions Help to address social needs Family support

11. Psychological interventions Treat drug / alcohol misuse –Increase motivation –Prevent relapse Address common co-occurring problems –i.e. anxiety or depression Can be delivered along side pharmacological interventions Self help and mutual aid

12. Pharmacological interventions Opioid Substitution Therapy –Methadone –Suboxone Assisted withdrawal from alcohol Alcohol relapse prevention –Acamprosate –Naltrexone –Disulfiram

13. Aiden is 22 years old. He comes to see you, the GP. He has lived in hostel accommodation for the past 4 months after moving from Bristol. The hostel staff have been increasingly worried about him because he is isolating himself in his room and they describe his behaviour as odd at times. A SAMH connect worker has brought him along to the surgery. The trigger for being encouraged to come along today is that he has been threatening suicide and the staff are concerned by this. The worker tells you too that he has permission from Aiden to tell you that he has been smoking four bags of heroin a day for the past two years on and off. He also had a hospital admission about six weeks ago following a heroin overdose but signed himself out and would not consider treatment. He is initially reluctant to speak at all. Describe what might help him to talk about his situation today, prioritise what might be done?

14. Knowledge Managing street drugs withdrawal Managing alcohol withdrawal Physical consequences of alcohol and drug dependency Safeguarding children Skills Good consultation skills Boundaries Mental health assessment Attributes Empathy

15. Further reading resources Macleod, J. Hickman, M. (2013) Early life influences on risk of injecting drug use. Addiction Apr;108(4):743-50 SMMGP web based resource for primary care orientated addiction guidelines –National “orange” guidelines 2007 –RCGP Substance Misuse –Dr Fixit case examples NICE Clinical Guideline 115 (2011) Alcohol dependence and harmful use