Contents
1.
2.
Street Drugs
Alcohol Treatment
7
27
Assessment
Detox
Motivational Interviewing
3
GP Activity
33
Assessment
DVLA
Biochemistry
4.
Prescribed Drugs
Pharmacy Activity
Blood Borne Viruses
Specialist Areas
Service Overview & Partner Agencies
Monitoring and Data Collection
Training & Clinical Governance
Appendices
SMMGP Website
Drinkwise London Ready Reckoner
Alcohol Detox Regime
Christo Inventory
Alcohol AUDIT
Opioid Withdrawal Scale
Useful Contacts
Substance Misuse Guidelines
54
55
56
60
61
65
Pregnancy
Enhanced Care
Criminal Justice
Keeping CDs in the Surgery
Complimentary Therapies
Reducing Drug Related Deaths
8.
9.
10.
11.
40
42
44
47
49
50
51
52
53
Writing Controlled Drug Scripts
Needle Exchange
Supervised Consumption
4 Way Agreement
6.
7.
34
35
36
39
Aims
Benzodiazepines
Methadone
Buprenorphine
Dihydrocodeine
Lofexidine
Naltrexone
Specialist Prescribing
5.
28
29
31
66
68
70
71
73
74
77
85
89
93
94
95
96
97
98
100
101
1
Foreword
Treating patients with drug and alcohol misuse is an ever increasing problem in our society. It affects
not only the patients themselves but also their families as well as the doctors, their practices and the
pharmacies involved in their care.
I am absolutely delighted that Plymouth is leading with the publication of the 2004 Substance Misuse
Guide Book.This offers practical and sensible help to health care workers dealing with this important
work in challenging circumstances.
It seems to be at the cutting edge of current practice and I warmly welcome it.
Nigel Meadows
HM Coroner Plymouth & South West Devon
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
For some time now there have been rumours of big changes occurring within the drug agencies.
Everything is seemingly in the pipe-line.This book is reassuring proof that these changes are underway.
It is obviously written with the addict in mind - plain english, straight forward and factual. It is
comprehensive and evidence of the positive support now available particularly for those who may not
have always wished to be involved. It is an invaluable aid to anybody who finds themselves working with
addiction.
This Guide Book inspires confidence in Service Users knowing that GPs, Pharmacists and other
workers can refer to it. After much hard work I feel that Plymouth is creating a very special drug
service.
Shona
Harbour Centre Trustee & Service User
Contributors
My grateful thanks go to the following colleagues for their vital input:
Avril Archibald
Russ Hayton
Anne Read
Alison Battersby
Sophie Hemming
Shirley Sinclair
Fay Berry
Peter Joliffe
Charlie Skinner
Maureen Bromage
Claire Meachin
Helen Tugwell
Dave Cartwright
Steve Mills
Marion Walker
Amanda Clements
Hilary Neve
Andy Whiteford
Hugh Campbell
Graham Parsons
Roger Williams
Chris Ford
Brian Pollard
Print & Document Services
This Guide Book is dedicated to Alan Hallett
2
Introduction
The earliest mentions of Substance Misuse date back to 3000 years BC when it was recorded that:
“anything that provides reward with little effort becomes abused by man”
Nothing has changed in this regard and addictive behaviours are also well documented amongst other
mammals. Interestingly the cost of funding the UK’s 35,000 GPs is less than what our drug users spend
themselves in maintaining their habit.
Welcome to the 2004 local Guide Book written unashamedly for Primary Care and other non-specialised
health and social care workers involved in Substance Misuse Management. These along with national
guidelines provide an important structure for us to develop increasing standards of care in this challenging
field. They offer a yardstick to measure the quality of care that is being delivered and changes from the
new GP Contract are being incorporated.
We do not intend to be totally comprehensive or to tell you what to do in every situation.
We have added a new chapter on Prevention of Drug Related Deaths and updated both the methadone
and buprenorphine sections. Our hope is to provide you with a useful day to day reference that is a
focused, local distillation of good practice.
References are provided to link you to other knowledge sources and please feel free to make contact
with any of the contributors.
Whilst there is broad agreement in many areas of practice, please note that certain areas remain
controversial. Updates will be supplied as developments occur.
The main focus for change at present is to bring down waiting times.
The new NTA (National Treatment Agency) has set a target of 2 weeks for the time between presentation
and commencing treatment by 1.4.2004. The motto is “more treatment, better treatment, fairer
treatment”. So there is plenty to be done. We are also hoping to bring service delivery closer to the
clients and to have link workers attached to practices to give greater support. Overall Plymouth requires
a robust system capable of operating at different levels and linking across many fields from Primary Care
to Prison or Casualty to Psychiatry.
The User and Carer voice is still sadly under-represented within our organisations. As with any
marginalised group we will need to take a very proactive lead if we are to hear this voice. Fortunately
from April 2004 Mike Jarman will be supporting the development of these groups following his
appointment by the DAAT (Drug and Alcohol Action Team).
Our thanks go to the many contributors listed opposite who have given their time to this publication.
This has very much been a joint venture and our hope is that substance users and their families in
Plymouth can benefit from a new climate of collaborative work around them.
Thank you for reading this and we look forward to receiving feedback via the Critical Review form on
the next page.
All correspondence can be sent to: St Levan Surgery, 350 St Levan Road, Keyham, Plymouth PL2 1JR
Tel: 01752 568228
Charlie Lowe
Plymouth tPCT Lead & GP Specialist in Substance Misuse
Steve Mills
Harbour Primary Care Team Manager
3
4
Critical Review for Personal Learning Plans
ALL RETURNED FORMS WILL BE SUMMARISED AND FED BACK AS AN OVERVIEW
Please record in order of importance the chapters in this Substance Misuse Guide Book that have been
most valuable to you:
MOST
LEAST
Your occupation:
Please record (as specifically as possible)
• what new learning has occurred?
• how will your practice be different as a result?
• how will you evaluate that these changes have come into effect?
What areas of learning have not been addressed?
How do you plan to address these needs?
What could help you achieve this?
Thank you for completing this review - please use more sheets as needed.
If you would like a meeting or written reply to enhance this evaluation then please contact
Charlie Lowe - details on page 3.
Name: ..............................................................................................
Name (optional)
.......................................
Date: ..............................................................
Date ...................
5
6
1. Street Drugs
7
Street Drugs Summary
Sedatives
Opiates
Others
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Benzodiazepines
Barbiturates
Psychotropics
Alcohol
Stimulants
• Cocaine
• Crack Cocaine
• Amphetamines
Heroin
DF118
Methadone
Codeine
Morphine
Diconal
Pethidine
Cannabis
Nicotine
E’s
Steroids
Solvents
GHB
Ketamine
Khat
Hallucinogens
• LSD
• Magic Mushrooms
Prices in Plymouth - January 2004
Alcohol
80p - £1.50 per unit
£7 - £15 bottle of spirit
£5 - £7 bottle of illegally imported spirit
Amphetamine (base)
£5 - 10 per gram (base £5 - £15)
Amyl/Butyl Nitrate (poppers)
£4 - £5 per bottle
Benzodiazepines
eg.Valium 10mg (blues)
Cocaine (charlie)
£35 - £50 per gram
Crack Cocaine (rocks, pipes)
£10 - £20
Ecstasy
£2.50 - £5 per pill
Heroin (brown, smack, H)
£60 per gram; also £10 and £20 bags
LSD (acid, trips)
£2 - £5 per tab
£1 - £1.50 each
Cannabis
£10 for 1/8th oz
Tobacco
£2.50 - £4.00 Illegally imported tobacco
often half price
Cannabis (skunk)
£10 - £16 per 1/16th oz; £140 - £160 per oz
8
Alcohol
We spend £32 billion a year buying it
Government collects £11.5 billion in Tax
Drinks Trade spends £227 million on Advertising
Government spends £1.1 million on Alcohol Services
Government spends £91 million on Drug Services
Source: Gisela Stuart MP (April 2001)
33,000 deaths per year estimated to be associated with alcohol misuse (a 33% increase since 1984)
1,000 drug related deaths per year
12% of NHS Expenditure linked to alcohol misuse
Positive alcohol testing in:
32 % ABH & GBH
36% joyriding
39% deaths by fire
46% criminal damage
75% breach of the peace
Source: NACRO (June 2001)
Acute short-term physical effects
Headache, blurred vision, loss of inhibitions, violence, loss of balance, trauma, arguments, blood shot
eyes, blackouts, poor concentration, restlessness, difficulty in sleeping, high blood pressure, rapid pulse,
vomiting, diarrhoea, inflammation of the stomach, fatty liver, trembling hands, falls, numbness in the
extremities, peripheral neuritis, bruising, impaired sexual performance, unwanted pregnancies, sexually
transmitted diseases, menstrual disturbances, reduced fertility, miscarriages, general dehydration.
Chronic long-term physical effects
Serious memory loss, damage to nerves, dementia, epilepsy, hallucination, chronic anxiety, depression,
poor eyesight, mouth cancer, metabolic disorders, throat cancer, oesophagael varices, cardiomyopathy,
anaemia, heart failure, impaired blood clotting, pancreas, hypoglycaemia, ulcers, liver cirrhosis, hepatitis,
liver cancer, back pain, kidney infections, foetal alcohol syndrome, impotence, peripheral neuritis,
muscle degeneration, malnutrition, general vulnerability to infection.
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
2. Alcohol Treatment
27
ALCOHOL
Assessment
It is estimated that a GP sees 364 excessive drinkers per year and that 1 in 25 have alcohol dependency.
Calculating intake is important to identify risk drinkers.
Watch out particularly with mental illness and drug misuse (crack and amphetamines obscures alcohol
dependency).
UNITS PER WEEK
MEN
WOMEN
LIGHT
1-14
1-10
MODERATE
15-21
11-14
FAIRLY HEAVY
22-35
15-21
HEAVY
35-50
22-35
50+
35+
> 10 per session
> 7 per session
VERY HEAVY
BINGE DRINKER
1 UNIT = 10g of alcohol
Calculation:
1 litre of 12% Wine
= 12 UNITS
1 litre of 4.8% Lager
= 4.8 UNITS
1 litre of 40% Whisky
= 40 UNITS
Assess volumes and strengths of different drinks according to the above.
% alcohol content w/v
1litre or 100cl or 1000ml
x
volume consumed
=
UNITS
See ‘The Drinkwise London Units Ready Reckoner’ in the Appendix
NB.
The old adage of:
1 unit = 1 glass of wine or 1/2 pint of beer or 1 short is prone to inaccuracy.
Another useful questionnaire is AUDIT - Alcohol Use Disorder Identification Test
A score of 5 or above suggests a risk of developing a problem.
A score of +/- 10 suggests dependency. See Appendix for details
28
Referrals
Send people who want to come ... not those that you think should
Joint assessments involving GPs are welcomed by Harbour. On receipt of referral and after discussion at
allocation meeting a letter is sent to new clients asking them to contact the service to make an
appointment.This helps to assess the client’s motivation to become involved which they demonstrate by
making contact.This keeps DNA rates down.
Following a comprehensive assessment covering physical, psychological, social, financial and forensic issues
a decision is taken as to whether the client wishes and would benefit from one of the following
interventions:
◆ Community detox
◆ Psychological treatments
◆ Hospital detox - PH of seizures/DTs/polydrug use/mental illness/isolated/risk of self-harm
◆ Residential Rehab
◆ Psychiatric input
◆ Joint working with another agency
◆ Shared care with GP
COMMUNITY DETOX
not a very frequent occurrence these days - 50% relapse in 3 months
Pre-detox Work
Enlist the support of a responsible adult for a minimum of 4 days
Drink diary & Leaflets to Client and Monitor = a responsible supportive adult
Explore Post-detox activities - Hamoaze House or Surgery Counsellors
Medication arrangements:
Chlordiazepoxide + chart (See Appendix)
+/- Thiamine:Vit B Cmpd Strong 2 tds for 6w if low risk
Pabrinex (Vit B&C) IV od 5d as In-patient if high risk
(Low risk: long history/poor diet/paraesthesia etc High risk: memory loss/DTs/W.E. etc)
Liaise with GP ref: GGT,FBC,BP and examination
DO NOT PRESCRIBE HEMINEVRIN / CLOMETHIAZOLE
IT IS VERY ADDICTIVE AND CAUSES RESPIRATORY FAILURE IN CONJUNCTION
WITH ALCOHOL
The Detox
START ON A SUNDAY
Daily visits or phone contact initially - whole course < 10 days
Support both Patient and Monitor
Adjust medication up or down as needed
Monitor vital signs if necessary
29
Post-detox Work
Possible Medication - Seek Specialist advice if uncertain
Acamprosate (Campral EC)
useful if cravings are marked 666mg tds or half if <60kg start 3d into
detox if necessary
response by 2w - continue up to 12m avoid in pregnancy/breast
feeding/liver&renal disease
Disulfiram (Antabuse)
severe interaction with alcohol
start after 1 w alcohol-free at 800mg on Day 1 reducing to 200mg od in
5d BEWARE aftershave, foods, medicines
still effective up to 7d after stopping
caution with CHD,HT,CVA,psychosis
Antidepressants
NB. At about 1 month after ceasing drinking many men experience a lift
in mood.
Offer Anxiety Management, Monitor Mood, Liaise with others
Relapse Prevention 3 Key Areas:
Boredom
Arguments
Peer Pressure
Motivation is not a trait that you either have or have not got. It is the probability that some one will begin
or continue to adhere to a specific change strategy. The cycle shown opposite demonstrates the stages
involved and therefore an appropriate action. So for example there isn’t much point discussing detox with
someone who is pre-contemplative.
An approach called Motivational Interviewing: Brief Intervention is being promoted locally to all workers
in the addiction field which builds on 6 elements using the mnemonic frames.
FRAMES
30
Feedback
– comprehensive assessment
Responsibility
– emphasis client’s personal responsibility for change
Advice
– involving ultimate goals or other referrals
Menu
– offer alternative strategies
Empathy
– not sympathy
Self-efficacy
– enhance client’s belief in ability to change
Motivational Interviewing
‘The Wheel of Change’
Precontemplation
Relapse
Contemplation
Maintenance
Determination
Exit
Action
Prochaska and Di Clemente’s (1982) six stages of change
Stages of Change and Therapists’ Tasks
Client Stage
Therapists’ motivational tasks
Precontemplation
Raise doubt - increase the client’s perception of risks and problems with
current behaviour
Contemplation
Tip the balance - evoke reasons to change, risks of not changing
strengthen the clients self-efficacy for change of current behaviour
Determination
Help the client to determine the best course of action to take in seeking
change
Action
Help the client to take steps towards change
Maintenance
Help the client to identify and use strategies to prevent relapse
Relapse
Help the client to renew the process of contemplation, determination
and action, without becoming stuck or demoralised because of relapse.
Miller & Rollnick, 1991
31
32
3. GP Activity
33
Give us a script Doc
So ....... what are you going to do?
It’s not a 10 minute job
30ml of methadone can be fatal so don’t rush for everyone’s sake
Get to know each other ... Build some respect ... Don’t make
promises that can’t be kept
Explore the motivation behind coming today - it’s vital for future plans
Why now?
CONSIDER
▼
WHAT ARE THEY USING?
– HOW MUCH?
– HOW OFTEN?
– WHAT ROUTE?
Remember ALCOHOL
IV = risk of BBVs
Education & Leaflets
Needle Exchange
Hep A&B Vaccination
Serology esp. Hep C
Stress confidentiality
Sick certificate
Sex worker support
Current employment
especially past 7 days
HOW IS IT FUNDED?
WHO ELSE IS INVOLVED?
Drug agencies
Probation/Courts
Social Worker
ANY SIGNS OF MENTAL ILLNESS?
Psychiatry
ANY URGENT PHYSICAL ISSUES?
Groins, Feet and Neck Injections Abscess, PID, Hep B&C
cause most harm - so check
Chest infection, DVT, HIV
CONTRACEPTION NEEDED?
Don’t assume infertility
Preg test/condoms
ANY CHILDREN IN NEED?
HV/At Risk Register
IS HOUSING ADEQUATE & SECURE?
Domestic Violence
Leaving with users
TREATMENT PLANS
WHAT HAS BEEN TRIED BEFORE & WHEN? - Residential or Community
HOW DID IT HELP?
WHAT ARE THEY HOPING YOU’LL DO TODAY?
34
NEXT STEPS
◆ Meet again to collect more information
◆ Urine screen to confirm use
◆ Arrange referral if you both agree it’s helpful
(depending on availability)
Social Services
Health Visitor
Child Issues
Keyworker
Fuller assessment
Calculate script
Hamoaze
Day services
Accupuncture
SMAT
Residential rehab
Hepatology
Hep B or C
Secondary Care Team
Complex cases +/- dual diagnosis
DVLA
It is the responsibility of the applicant to inform the DVLA of any conditions that may affect their ability
to drive, which obviously involves drug and alcohol dependency.
Detailed advice can be sought from the DVLA website at www.dvla.gov.uk.
Applicants or drivers complying fully with a supervised oral Methadone or Subutex maintenance
programme from a specialist can be licensed subject to favourable assessment and normally annual
reviews.This applies to Group 1 entitlement only and not for vocational drivers.
There will be occasions when patients/clients decline to inform the DVLA despite regular
encouragement. It may then be our public duty to do this and discussion with colleagues will help reach
the right decision.
35
BIOCHEMISTRY
Currently the most popular method of testing for drug use is via urine screening. Testing is by
immunoassay with adjustable thresholds of detection using the Roche Integra automated analyser.
This is not a precise science and at times results are complex to interpret. Nonetheless screening offers
some important safeguards for maintaining safe treatment and honesty around use on top of scripts.
A prescription should not be started until receipt of a positive urine result to confirm use.
The analyser is run once every weekday when all received samples are tested.There is no ‘waiting list’ so
senior laboratory staff can provide telephone confirmation the day after the sample arrives. Subsequent
testing is at the clinician’s discretion with increasing intervals as a new treatment stabilises.
Random screening to monitor illicit drug use and ensure that prescriptions are being taken
by the client are a mainstay of monitoring and at a minimum should occur three times a
year.
Tests are not a punishment
but a way of ensuring that the prescription is right
Urine Screening
The appropriate specimen for urine screening is 20-30ml which should be stored in a sterile plastic
container without preservative. Special care should be taken to ensure the specimen is authentic and not
adulterated. Store in a fridge overnight.
Creatinine measures of < 2 mmol/l suggest extreme dilution. Recommended checks include testing the
temperature of the specimen by placing the container in the palm of the hand and asking the client to
leave bags outside the room where collection is to take place.
Specimens can be dispatched to the Lab up to 4 days after collection without altering the result.
OFT (Oral Fluid Tests) will become more common place over time as they offer greater reliability for
sample collection and client dignity. Instant urine tests are also available covering the 6 drugs tested on
the regular Lab screen.They cost £10 per strip with a 12 month shelf life.
Assay Request Form
Please include the following relevant details
on the form:
• patient’s identity
• date and time of specimen collection
• drug to be tested for
• all prescribed medication
PLEASE NOTE that Buprenorphine (Subutex)
can only be detected by OFT (Oral Fluid Test),
now available through Harbour Teams.
Do not request Opiate Identification unless
there is a very good reason to do so as this is
a labour intensive process involving 4 hours of
a technicians day.
36
Approximate Detection Times of Common Drugs of Misuse in Urine
Amphetamines ( including MDMA, MDA )
Up to 1 day
Barbiturates
1 - 3 days
Benzodiazepines (depending on half-life)
8 hrs - 2 days
Cannabis
28 days
Cocaine
1 - 2 days
Codeine
1 - 2 days
Heroin ( Morphine )
15 - 44 hrs
Methadone
1 - 4 days
Possible Action Plan on results with Methadone maintenance
METH POS
OPIATE NEG
Doing well
METH POS
OPIATE POS
Using on top
METH NEG
OPIATE POS
? using script
METH NEG
OPIATE POS
despite daily supervision - reassess
METH NEG
OPIATE POS
despite new plan - stop script
daily supervision
Drugs That May Give Rise to Positive Screening Results
Prescribed Opiates
Prescribed Amphetamines
Codeine
Dihydrocodeine
Morphine
6-monoacetylmorphine
D and L Amphetamine
Methamphetamine
Dexedrine
Over the counter preparations ( OTC )
MDA
MDMA
Ephedrine
Norpseudoephedrine
Phenylpropanolamine
Pseudoephedrine ( Sudafed )
Phentermine
Fenfluramine ( Ponderax )
Other stimulant drugs
Benylin
Calpol
Co-Codamol
Co-Dydramol
Kaolin & Morphine
Paracodol
Pholcodine
Propain
Poppy seeds
FOR FURTHER ADVICE CONTACT:
ROGER WILLIAMS - BIOCHEMIST DERRIFORD COMBINED LABS - TEL: 01752 792401
37
38
4. Prescribed Drugs
39
AIMS OF GOOD PRESCRIBING
Never forget that you are the most powerful component of any consultation.
Providing a non-judgmental and empowering relationship is the most effective part of the
work you do.
Most clients hold doctors in very high regard and the impact of your commitment to their case can be
considerable in energising their motivation to make changes.
Life with addiction is always rather disorganised
Attending appointments can be helped by asking the Pharmacy to give
your patient a reminder on the day or using text messaging
The harm reduction philosophy will be the main influence on our work but there will be a place for
abstinence based approaches as well.
PLEASE DO NOT HAND PRESCRIPTIONS DIRECTLY TO YOUR PATIENT
This exposes them to temptation and greater risk of diversion
Use Pharmacy vans for collection, the post, or deliver in person
Aims
1. Alleviate withdrawal symptoms and stabilise the client - detox as appropriate
2. Promote a process of change in an individual’s drug taking & risk behaviour
3. Ensure a safe delivery of a prescribed treatment plan
4. Support and compliment the chosen harm minimisation strategies that develop from the client’s
treatment plan
NB. Stopping a script can be a positive intervention involving reassessment and promotion of both
contact and consistency.
Possible Outcomes
This section is open to many opinions depending on which agenda is addressed i.e. research, government,
police, public health, service user, service provider etc.
• reduce illicit drug use
• decrease need to turn to crime to fund habit
• decrease risk behaviour - injecting or sexual
• promote stability in lifestyle changes
• improve the user’s quality of health
• improve personal, social and family functioning
• reduce the overall drug use possibly leading to abstinence
Check out www.ntors.org.uk for details of the National Treatment Outcome Research
Study which indicated that £1 spent on health saved £3 in crime.
40
Holiday Prescriptions
Any client doing well on their programme deserves a
holiday like the rest of us.
With advanced warning you can contact another
Pharmacy in the UK for dispensing or arrange
collection of a larger quantity sometimes monitored
by another responsible adult. Book an appointment
on return in case ‘the holiday from hell’ triggers a
relapse!
A covering letter is helpful in case medical help is
needed while away. Methadone tablets can be issued
if there is a risk that bottles of liquid may get broken.
EXPORT LICENSES
from the Home Office Drugs Branch Licensing Section Tel: 0207 273 3855
These are required for trips abroad if you travel with more than:
• 500mg of Methadone
• 140mg of Subutex
• 900mg of Diazepam
Fax your request to:Tel: 0207 273 2157
Stating:
• Name • Address • D.O.B. • Countries of travel • Date of departure & return
• Name of drug • Form (tabs/liquid/amps) • Strength Quantity
The Export Licence is sent by post to the patient with details of how to contact the relevant Embassy or
Consulate as in some cases like Spain an Import Licence is required.
Again a covering letter is helpful in case medical help is needed while away.
41
Benzodiazepines
Dependency on these drugs has been an increasing problem since the 70’s. Historically there has been
more prescribing in Plymouth than in many other parts of the UK, hence the current CHI initiative.
The evidence for the value of methadone maintenance prescribing is overwhelming while
there is none for benzodiazepines. Despite this fact many doctors feel more comfortable to
prescribe them than methadone.There are also real concerns that GP prescriptions may become diverted
onto the illicit market particularly into the hands of opiate users (around 30% co-use). Random urine
screening on the elderly with long-term, 4-8 week benzo scripts may produce some interesting results
for the prescriber. Of course large scale illicit benzo suppliers and dealers are also responsible for
availability. Over the next year our Clinical Governance activity will be aimed at clarifying positive changes
in practice to improve the situation.
There is no license to use benzos to treat dependency unlike for methadone. Users will often
stockpile tablets for bigger effect. Evidence suggests that high dose long-term use is associated with
cognitive impairment and neurological damage. Also studies show higher risk behaviour in users with
greater rates of Hep C and HIV infection, overdose and criminal activity. This is confirmed by
trends noted by Nigel Meadows the Plymouth Coroner. Its disinhibiting effect causes much of the
trouble and is a point well worth explaining to users needing reasons to change their use.
Perhaps its use is often a negotiated bribe to retain a client in treatment?
Withdrawal symptoms are worse the longer the use. It is a difficult drug to work with in a
treatment programme as it cannot be given once daily by supervised consumption. So much for the
replacement of Barbiturates promoted in the ‘60’s.
Please note that Zopiclone is now a drug of abuse also.
The Philosophy of Benzo Prescribing Regimes should be:
• ALL NEW SCRIPTS TO BE DISCUSSED BY THE TEAM BEFORE INITIATION
Doses over 30mg will only be considered under exceptional circumstances.
• Convert to Diazepam since it is the most long acting
It has less ‘buzz’ than shorter acting temazepam
There is no indication for using 2 benzos - see conversion charts in BNF
• ALL CHANGES SHOULD BE DONE WORKING WITH THE PATIENT
A ‘bad tempered’ script benefits no one
The prescriber should not force the pace
• Prescribe for as short a period as possible: < 6 months
Keep short-term use to < 2 weeks e.g. stress back spasm
• Daily Dispensing.
Currently GPs have to issue 12 separate scripts to cover a fourteen day period (Mon to Sat + Mon
to Sat) of daily pick-up.The CDS have a separate scheme involving just one script and we are
exploring ways of GPs doing the same. 12 scripts is the safest system at present, but if this is not
possible then twice weekly scripts are much safer than a weekly supply.
• ALL SCRIPTS SHOULD BE REDUCING
A few people will benefit from long-term low dose (<30mg) diazepam daily on the grounds of causing less
harm than stopping the script.This may apply to alcohol dependent users or those with chronic anxiety.
Seek Specialist advice to confirm.
42
Reduction Regimes - these are all gradual
• by 2.5 to 5mg every 2 weeks until 30mg daily then
• by 2mg every 2 weeks to zero
Withdrawal symptoms can be troublesome and good commitment is needed by the client.
They can persist for between 10 months and 31/2years in a third of drug users.
The regular help of a supportive Pharmacy is invaluable in this slow process.
Promethazine 25-50mg nocte or Perphenazine 4mg nocte can help with insomnia.
Some centres use Hydroxyzine (anti-histamine) 25mg nocte or up to 25mg q.d.s. to help with anxiety post
detox for 2-4 weeks maximum.
The preferred anti-depressant to use would be Lofepramine or Trazodone. At the end of the regime
dividing the daily amount into 2 or 3 doses and using elixir can be helpful.
Why do drug users use Benzos?
Anxiety
Insomnia
‘To get high’
Depression
Reduce ‘voices’
Enhance methadone effect esp. temazepam
Help come down from stimulants (amphetamines, E’s, cocaine or crack)
43
Methadone
– Physeptone
Methadone is an opioid originally formulated in WW II for analgesia by German Pharmacologists. Since
then it has become the mainstay of opiate dependency substitute treatment. It represents one of the
most highly researched and successful treatments ever.The table indicates its notable attributes.
POSITIVE
NEGATIVE
Oral - not injectable
Very addictive
Once daily dose
Difficult detox agent
Non-euphoriant
(relative benefit)
Established side-effects
It has witnessed many changes in its history. Initially it was used in New York prisons during the 60’s by
Dole & Nyswander in a context of “medical treatment” as insulin is given to diabetics.Their high quality
studies excluded any alcohol or polydrug users but showed good results with daily methadone
maintenance at doses of 60-80mg.This compared with high relapse rates from detox.
In the 80’s - as response to HIV - programmes shifted focus to draw more IV users into the harm
reduction net and so more flexible and lower dose regimes came into use. (This was not so effective in
reducing the spread of Hep C however).
The 90’s Government NTORS study of 1075 drug users followed over 5 years through different
treatment settings, revealed £1 spent on Health saves £3 on Crime. This has lead to the NTA drive to
double the number of users in treatment in the decade to 2008.
We are left as prescribers with the dilemma of balancing:
The Individual’s needs v Public Health considerations
PRESCRIBING REGIMES:
Maintenance +/- planned reductions/ Detox.
Slow detox regimes are not recommended due to high drop out rates.
MAIN AREAS OF BENEFIT
SIDE-EFFECTS
▼ opiate misuse
• Constipation
▼ non-opiate misuse
• Sweating
▼ crime/prison
• Weight gain
Employment/college
• Dental problems
▼ HIV risk behaviour - injecting
• Nausea
▼ death rate
• Amenorrhea
▲ quality of life
• Depression/lethargy
▼ HIV risk behaviour - sexual
• Reduced libido
▲ physical & psychological health
• Itchy skin
Note – Heroin causes most of these symptoms also
44
INITIAL DOSING
• Start low 10-20ml/d if dependency is uncertain
• Use 25-40ml/d if known dependency
Increase by 30ml over a week
until satisfactory level reached
Assess tolerance by:
– past use history: quantity/frequency/route smokers
may need less than injectors
– past methadone experiences
– also consider alcohol & Benzo intake
– a potentially lethal combination
Titration is a balance between
withdrawal symptoms and death
Rough Conversion
Heroin
Methadone
1/4g
15-30mg
1/2g
30-50mg
1g
50-80mg
A “teenth” is 1/16th of an ounce = 1.75g
(Street heroin is on average 45% pure)
Dosage
Start Dose: 10-40mg daily
Peaks in 2-6 hours
Maintenance dose: 5 to 100mg (Rarely >150mg)
Seek specialist advice if needed
10 fold variation in metabolism
Elimination half life 24 to 36 hours (range 10 to 80 hours)
Split dose occasionally helps if fast metabolism
Remember 7 days to steady state plasma level
The correct dose of methadone is arguably the one that retains the client in treatment and enables useful
lifestyle changes. Consider the length of a user’s habit, their lifestyle, their social contacts, the ‘distraction’
in their lives - work, childcare etc. - when establishing a prescription plan. Capelhorn in Australia found a
4 fold increase in drop out rate for clients given a daily dose of below 60mg as compared to doses of
over 80mg.
Caplehorn JRM, Bell J. Methadone dosage and retention of patients in maintenance treatment. Med J Aust 1991;
154:195-9
45
Miscellaneous
Use is satisfactory in chronic “steady” liver disease
Remember elimination ▲ by rifampicin, disulfiram and phenytoin
Elimination ▼ with fluvoxamine
Sugar and colour free preparations are available for true intolerance but are also more injectable
Tablets no longer recommended by ACMD due to diversion into injections with high thromboembolic
and infective risk due to powder particles
Amps are available for Specialist use for injectable regimes
Martindale Representative:TBA
Methadone Dose / Volume Calculator
Daily Dose
10ml
15ml
20ml
25ml
30ml
35ml
40ml
45ml
50ml
55ml
46
14-Day
Supply
140ml
210ml
280ml
350ml
420ml
490ml
560ml
630ml
700ml
770ml
Daily Dose
55ml
60ml
65ml
70ml
75ml
80ml
85ml
90ml
95ml
100ml
14-Day
Supply
770ml
840ml
910ml
980ml
1050ml
1120ml
1190ml
1260ml
1330ml
1400ml
Buprenorphine
– Subutex
First licensed for drug dependency treatment in 1999 having been around for years in lower doses as the
analgesic Temgesic. It is a semi-synthetic derivative of opium with important properties not found with
methadone. From 1.4.03 trained GP practices have both drugs placed within the High Cost Drug category
to prevent any penalties to their prescribing budgets.The cost of buprenorphine 8mg/d = £1,100 p.a. and
methadone 50ml/d = £277 p.a..
Its most striking advantage is safety with far less risk of overdose. A young child in France
accidentally consumed large quantities without any adverse effects. This relates to buprenorphine’s dual
action as an opiate agonist (so relieving withdrawals) and also as an antagonist - rather like heroin and
naloxone rolled into one. Using on top becomes a waste of money.
Like methadone it has a long half-life of 20-25 hours and some clients manage alternate day dosing. It has
low euphoric effects through out its dose range and opiate blockade is usually achieved between 8 and
16mg daily. It can be used for maintenance and detox. It is easier to come off than methadone in the main
especially if maintenance is only a few months.
Detox regimes over 5 weeks reducing from 8mg to 6mg to 4mg to 2mg to 0.4mg work well and faster
14 day regimes are used. It is now common practice to use buprenorphine as first line Rx for short term
heroin users who have not tried methadone before as with Young People.
It is administered sub-lingually and effective within 1-2 hours peaking at 6 hours. It can be easily supervised
- the client drinks some water then places the tablets under the tongue. After 3 minutes the drug is
absorbed and the remaining chalk can be swallowed. Tablet strengths are 0.4mg, 2mg and 8mg.
Methadone will continue to be a mainstay of maintenance prescribing for many years to come and
remains the drug of choice for certain client groups.These would include clients with successful
long-term scripts and also clients whose psychological state may decompensate without it. Methadone
can act like a ‘psychic glue’ for some clients who carry large amounts of trauma memories which it is not
wise to release. Buprenorphine allows a ‘clearer head’ which clients do not always appreciate or consider
timely.
Induction Routine
Medical assessment, urine screen and LFTs first.
Induction only works if the client is in good withdrawals from heroin before the start of treatment (see
Withdrawal Scale in Appendix). RCGP 2003 Guidelines recommend 4-8mg initial dose (1993 license
differs) with a typical maintenance dose of 8-16 mg daily. Be prepared to use higher doses, especially
if street use is high or such a dose has been needed before, or you will loose the client due to
withdrawals. A few low level heroin or DHC users may require less.
Clients can be very disturbed by unpleasant prescribing experiences so good preparation is
essential along with readily available support in the first 3 to 5 days. The use of loperamide,
ibuprofen or promethazine can help early on and occasionally lofexidine. Generally induction is relatively
straightforward and co-prescribing is not routine.
Conversion from methadone is better at doses of 30mg or less and again the client needs to be in
withdrawals to switch - so 24-36 hrs since last use.Transfers at higher doses of methadone can be done
as an in-patient or with lofexidine in the Community.
47
Other issues
◆ there is a street value due to its injectability when the antagonist effect is less marked - so avoid using
if there is a substantial history of injecting
◆ current local urine screening will not detect it - indeed request forms don’t mention it. Samples have
to be sent to Birmingham so please request testing in order to confirm usage
◆ longer experience of use in France and USA than in UK
◆ side effects can be constipation, insomnia, dizziness, asthenia, sweating, rarely liver problems,
respiratory depression and hallucinations
◆ enhanced CNS depressant effects can occur when used with opiates, MAOIs, antidepressants,
barbiturates, antitussives and especially benzodiazepines and alcohol
◆ increasing use in pregnancy although not licensed
Schering Plough Representative: Hayden Loveless Tel: 07774 767762
Highly recommended reading:
48
Dihydrocodeine
– DF118
Dihydrocodeine is not licensed for use as a maintenance treatment for opiate dependency.
It is much more easily abused than the long acting alternatives.
Consequently its use should be reserved for the end-stage of methadone detox only when
its short acting nature produces a shorter duration of withdrawals.
GP Out of Hours Centres and Locum GPs are a favourite haunt of
the opiate dependant looking for free supplies.
1 x 30mg DHC = ~ 3ml of methadone
so 100 x 30mg DHC = ~ 300ml of methadone
SO PLEASE PRESCRIBE SMALL QUANTITIES IF AT ALL
49
Lofexidine
– BritLofex
a non-opioid tool for detoxification
After long-term opiate use the brain develops an increased number of noradrenaline receptors as a
response to the suppressive effects on noradrenaline production by the opiates. Abrupt cessation of
opiate intake produces a “noradrenaline storm” leading to the familiar withdrawal symptoms. Lofexidine
binds to the noradrenaline presynapse (Alpha2-adrenergic agonist) leading to a decreased release and
turnover of noradrenaline so treating the withdrawals. It has no effect on opiate receptors themselves
and does not have the addictive qualities of other detox agents. Its structure is similar to Clonidine which
is not licensed for this use.
It represents a useful alternative in the field of community and in-patient detoxification and
is widely used in the Prison sector. It can also facilitate higher dose Methadone to Subutex transfers.
Tablets come in a single dose of 0.2mg and a pack of 60 costs £74.44
Exclusion criteria
◆ Pulse < 55 bpm
◆ Systolic BP < 90 mm Hg
◆ Systolic > 30 mm Hg below baseline
◆ CHD or HT or CVA
◆ Pregnancy or Breast feeding
◆ Heavy drinking or high benzodiazepine use
Treatment Regimes
Positive urine screen for opiates
Client preparation - as usual essential (video/guide available from Britannia)
Start on a Monday when better support is available
Start 6 hours after last use of heroin/DHC and 24 hours for Methadone
Monitor P & BP at least 3 times within first 5 days then around 7 and 10 days
Regimes typically last for 7 to 10 days with 4 doses spread across the day
The dose has to be stepped up from 4 tablets on Day 1 to a maximum of 12 tablets per day by Day 3
aiming for a maximum dose as opiates are removed
For example:
Day 1
2 tabs b.d.
Day 2
2 tabs q.d.s.
Day 3
3 tabs q.d.s.
Having reached the highest dose required maintain this until Day 10 then reduce dose to zero over 3-5
days.
Adjust the dose to relieve the symptoms.Too much and the client will be dizzy and hypotensive.
Britannia Representative: Liz Roberts Tel: 07879 433806
50
NALTREXONE
– Nalorex
Naltrexone is a long-acting opiate antagonist used to provide a sustained period of opiate abstinence as
an adjunct to other therapy and social support. It is the tablet version of Naloxone which is used in the
reversal of respiratory depression caused by heroin or opiate overdose. It is non-addictive with no
psycho-active effects. Naltrexone preferentially occupies the opiate receptors so blocking the effect of
any opiates - heroin, methadone, buprenorphine, dihydrocodeine and codeine - taken at the same time.
It is the only agent licensed for the maintenance of abstinence as opposed to maintenance therapy.
Outside of the NHS implant versions are used.There is evidence that it reduces the craving for opiates
felt by addicts and acts as a break on impulsive drug use triggered by high risk situations. Clearly the client
must demonstrate a high motivation to become and remain opiate free.
It is rapidly absorbed orally with extensive first-pass liver metabolism. Peak plasma concentrations are
produced by 1 hour and excretion is through the kidney.Tablets come in a single dose of 50mg - yellow
and scored. It has a hepatotoxic potential so LFTs prior to and at 3 monthly intervals is recommended.
Seek Specialist advice for abnormal results.
Commencement of treatment needs to be carefully planned as there is the potential of generating the
mother of all withdrawals if the client is not adequately opiate-free when starting the Naltrexone. The
withdrawals will be rapid in onset (within 5 minutes) and severe if the Naltrexone preferentially replaces
any opiate agonists from the receptor site. 48 hours of vomiting and diarrhoea is not uncommon. As a
result intravenous and oral challenges have been developed to ensure that a client is ready to commence
treatment.
It is recommended that clients be opiate-free for a period of 7 to 10 days before starting. With
buprenorphine (or Subutex) it may be possible in 4 days. Urine screening can assist confirmation.
Depending on the situation (particularly favoured in prisons) a naloxone IV challenge can be performed.
0.2mg is injected followed by a further 0.6mg after 30 seconds if no reaction occurs. The challenge is
considered negative if no withdrawals are seen within 30 minutes. The usual starting regime is 25mg on
the first evening followed by 50mg daily thereafter. For improved compliance and supervised consumption
the typical regime is 100mg on Monday and Wednesday with 150mg on Friday. In the absence of a
naloxone IV challenge, a clinician can be confident that no reaction will occur if no withdrawal symptoms
have resulted 1 hour after ingestion of a tablet.
Treatment is likely to be for at least 3 months and incorporated into a comprehensive treatment package.
Opioid addiction is a chronic relapsing condition so outcomes need to reflect this context nonetheless
this is promising new treatment option. Mild withdrawal-type side-effects may occur in the first 2 weeks.
Clients need to carry a Medical Alert Card and check OTC remedies for opioid content. There is no
clinical experience of overdose and no toxicity reported in volunteers receiving 800mg daily for 7 days.
Data on interactions is limited and use in pregnancy is reserved to cases where potential benefits outweigh possible risks.
CAUTION:
Following a period of opiate abstinence tolerance will reduce
so relapses immediately after a client has stopped Naltrexone
have a greater risk of overdose
if he/she re-scores heroin in quantities previously used
51
SPECIALIST PRESCRIBING
DEXAMPHETAMINE Dexedrine
Amphetamine misuse is a common feature of the Plymouth drug scene. Although there is no concrete
physical withdrawal syndrome the ‘come down’ is very unpleasant and may consist of acute depression,
free-floating anxiety, loss of confidence and malaise.The latter is partly due to exhaustion and unhealthy
life-style but also the loss of artificially-stimulated high energy levels. As tolerance develops the user is
more likely to inject to get the ‘rush’.
Chronic use leads to paranoia and rarely psychosis. Amphetamine was in its time a successful antidepressant and appetite supressant so look carefully for masked depression and eating disorders.
A selected group may benefit from short-term prescribing with either elixir or tablets. The typical dose
is 20-50mg often split into two doses avoiding bedtime doses that result in insomnia. Safety around
storage needs discussion.
CHECK FOR HYPERTENSION
Contra-indications:
– History of Psychiatric illness
– Hypertension
DIAMORPHINE
Special Home Office licenses for using this in dependency treatment are currently held by Drs Alison
Battersby and Charlie Lowe in the City.
A few clients stabilise on this and nothing else. They must have tried methadone first. Prescriptions are
mostly injectable with a few oral. Some clients require a small night time methadone dose to avoid
morning withdrawals. Dispensing is daily with tighter monitoring due to the increased risk of diversion.
Only a few areas in the country offer this service and its future is under review by the NTA. Projects in
Holland and Switzerland have been successful in developing safe shooting galleries. At present 35
diamorphine clients cost an average of £5,000 p.a. compared with the average methadone cost of £250
p.a. so with budgetary pressure availability is exceeded by demand.
Rarely pragmatism may dictate prescribing the client’s drug of choice e.g. MST or Oramorph. Close
monitoring is needed with gradual transfer to methadone unless reduction will occur in the near future.
Cyclimorph, Diconal, Pethidine and Palfium should never be prescribed.
52
5. Pharmacy Activity
Graham Parsons
the DAAT Pharmacy Lead
at the Ryder Road
Pharmacy
can be contacted on
01752 607219
53
Writing Prescriptions for Controlled Drugs
with Instalment Dispensing
BLUE SCRIPTS
1.
The prescription must be in ink (or otherwise be indelible) and be signed by the person issuing it
with their usual signature and date of signing.
a.
Rubber date stamp is acceptable BUT computer-generated dates are not acceptable.
b.
“faxed” prescriptions are NOT acceptable.
2.
Specify the name and address of the person issuing it and of the patient.
3.
Specify the dose to be taken, the AMOUNT of the instalments to be supplied
AND THE INTERVALS to be observed when supplying.
There must be a minimum of TWO instalments on a Blue script.
Home Office states there should be “no room for interpretation” and “clarity”.
Acceptable statements include:
i.
“Sunday’s dose to be dispensed on Saturday”
ii.
“Bank Holiday dose to be given on preceding pick-up day.
Bank Holiday dose “as appropriate” is NOT acceptable
iii.
Best Practice is to SPECIFICALLY indicate dates and quantities of instalments to be
given on Saturdays and Bank Holidays.
iv.
Bi or Tri weekly pick ups MUST state the EXACT days for collection
i.e.Tues & Fri. Note if the patient fails to collect on the specified day then they
forfeit that whole instalment.
v.
Monday/Tuesday/Wednesday/Thursday/Friday/Saturday/Sunday
Delete as appropriate.
4.
Specify the form, the strength and the TOTAL quantity in WORDS AND FIGURES
Abbreviations “t”,”c” or “m” are not acceptable but “tabs”, “caps” or “mixt” are
Only the total quantity needs to be expressed in words and figures and not
individual dosage units.
5
There is no legal requirement for a start date to be specified BUT where one is given it MUST be
complied with and instalment directions must run from that date.
a.
If the “start date” falls on a bank holiday and the supply for that day would be given
prior to that start date the prescription MUST be dated on the day the first supply
would be given.
b.
Where no start date is given the first instalment must be dispensed within 13 weeks
of the date specified on the prescription.
6.
If the prescription is for supervised consumption then please mark the prescription “Supervised
Consumption”. While not a legal requirement this will prevent any misunderstanding between
the GP and pharmacist and ensure the medication is consumed on the pharmacy premises.
7.
Home Office hand writing exemptions certificates are available if you have more than ten
patients with drug dependency on daily Controlled Drug instalment prescriptions.
Contact Charlie Lowe for details.
8.
Use a Green FP10 for single pick-up Holiday Scripts.
54
NEEDLE EXCHANGE or NX
This free and confidential service is aimed at reducing virus
transmission. Started in 1990 it is offered by the Harbour
Centre, 14 Pharmacies and an Outreach delivery service.
The later is required for Tavistock, Kingsbridge, Estover
and Leigham due to a lack of Pharmacy involvement.
Deliveries are also offered to a few chaotic users
where closer contact allows safer injecting technique
education and encouragement to engage with other
treatment services.
Steve Reeves is the Harbour Co-ordinator.
Nationally 50 million “pins” are issued per year in the
UK and 750,000 in our City which is 3 times busier
than most other NX schemes. Plymouth has a very
strong injecting culture and lately users have been injecting crack despite there being
absolutely no advantage over smoking it. It is estimated that about 1500 IVDUs access
the service here with yearly growth.
Interestingly some states in the USA have banded needle exchanges along with methadone.
Harbour Ermington Terrace Exchange Opening Times
Monday
Tuesday
Wednesday
Thursday
Friday
09.30
09.30
13.30
09.30
09.30
-
17.30
17.30
17.30
17.30
17.00
Pharmacies offering Needle Exchange
• NCC Pharmacy
King Street
Stonehouse
• Stolton Pharmacy
15 Cumberland Street
Devonport
• Tugwells Pharmacy
17 Wolseley Road
Milehouse
• Superdrug
74 New George Street
City Centre
• Comptons Pharmacy
146 Eggbuckland Road
Higher Compton
• O'Gallagher Pharmacy
91 Church Road
Plymstock
• NCC Pharmacy
640 Wolseley Road
St Budeaux
• Moss Chemist
Embankment Road
Prince Rock
• NCC Pharmacy
6 Ham Green
North Prospect
• NCC Pharmacy
324 Old Laira Road
Laira
• Knowle Pharmacy
Honicknowle Green
Honicknowle
• Mike Smith / Moss
2 Erme Terrace
Ivybridge
• NCC Pharmacy
77 Whitleigh Green
Whitleigh
• NCC Pharmacy
7 Hornchurch Road
Ernesettle
55
SUPERVISED CONSUMPTION SCHEME
Pharmacists’ changing and expanding role as the NHS modernises has provided greater opportunities for
community pharmacy involvement in providing healthcare services. Some Pharmacists have developed
close working relationships with clients, supporting them and often their families. Many Community
Pharmacies dispense for several members of a client’s family and it maybe they first turn for help here.
Just getting the client into treatment has enormous benefits, to the client, their family and the community
locally. Despite its time consuming nature Pharmacists have in the past provided supervised consumption
without payment for certain clients - the harm reduction benefits being far reaching let alone the
increased confidence all the healthcare workers involved feel. Getting involved on this level does highlight
to the Pharmacist and their staff, that open lines of communication with other healthcare workers is very
important and that there is a need for a co-ordinated approach within the Pharmacy.
In May 2003 a new scheme with its own detailed operational policy was launched across most of the 48
Plymouth Pharmacies. In Glasgow 90% of their 6,000 users are having supervision. It is a direct response
to concerns about drug related deaths and the risk of diversion.The Orange Book recommends a period
of at least 3 months of supervision at the start of a script and the option of reintroducing this if a client
is beginning to relapse. New funding will reimburse Pharmacies for this service with a retainer of £300
per annum and £1.80 per supervision. Funds are also available for alterations to premises to provide a
private space. The responsible Pharmacist will train staff at their premises, complete the CPPE Opiate
Treatment Package and contribute to annual audit exercises. Training for technicians is important too
bearing in mind the increasing use of locums who do not have continuity with the clients.
This new scheme represents a valuable advance in treatment and has also provided important
opportunities to improve communication with Pharmacies which is a vital though often neglected area.
After all no other health care workers see so much of the clients with daily pickup arrangements and
early warnings of problems from the Pharmacy contributes directly to relapse prevention. The 4 Way
Agreement on the next page can be used as part of all arrangements for drug users attending a Pharmacy.
A recent user group were concerned about breaches of confidentiality occurring and sometimes a
judgmental attitude in Pharmacies. Many people talk openly and loudly in a Pharmacy seeing it as a public
place, but equally when dealing with private issues there are challenges of confidentiality that should be
addressed. Please be sensitive to the issues of courtesy and respect in both directions to prevent pickup
becoming a punitive and irritating experience. If problems arise then please ring the keyworker or
prescriber who are there to provide support to you.
56
56
Substance
MisuseGuidelines
Guidelines
Substance
Misuse
Claim Form to be attached to Blue Script.
Substance
Guidelines
SubstanceMisuse
Misuse
Guidelines
57
57
The Supervision Process
Each Pharmacy will have a slightly different procedure for supervising clients in terms of where in the
Pharmacy and at what specific times the client should arrive. These times will often not be the same as
the Pharmacy’s opening hours. Initially the Pharmacist and client will discuss the 4-Way agreement and
any additional information the client may need about what will happen during the supervision process.
Key members of staff would normally be introduced at this stage.
Methadone
Subutex
Assessment for supervision
? Non collection of two consecutive doses
? Intoxicated
Go to 1 or 2
Assessment for supervision
? Non collection of two consecutive doses
? Intoxicated
Go to 1 or 2
1. Discussion with the client about why you are
withholding supervision. Contact other
healthcare workers.
If Saturday collection decide if Sundays doses
should be withheld
1. Discussion with the client about why you are
withholding supervision. Contact other
healthcare workers.
If Saturday collection decide if Sundays doses
should be withheld
2. Go ahead with the supervision
2. Go ahead with the supervision
Dispensed product to be examined
Dispensed product to be examined
Drink directly from the bottle or the Pharmacist
can pour it into a cup
Drink some water
Drink with one or two mouthfuls in front of
Pharmacist
Pharmacist pops tablets into hand/pot and client
places under tongue
Drink half a cup of water afterwards out of the
Pharmacists cup and return bottle or cup to
Pharmacist
Client sits/stands within sight of Pharmacist while
the tablets dissolve about 3-5 minutes
Additionally may need to talk to Pharmacist to
ensure dose is swallowed
After tablets have dissolved (Pharmacist may
want to check clients mouth) if not
Client can normally leave the shop 4 minutes
after supervision began when the Pharmacist has
acknowledged to the client they are happy for
them to go (active ingredient has gone after 4
minutes, some chalky residue maybe left)
Entry made in records and feedback any
concerns to other healthcare workers
58
58
Entry made in records and feedback any
concerns to other healthcare workers
Substance
MisuseGuidelines
Guidelines
Substance
Misuse
Client Leaflet
Why have I put on Supervised Consumption?
In response to a rise in the number of deaths and accidents related to Methadone in
recent years, the Department of Health issued guidelines in 1999 that recommend it
is provided more safely. Subutex (buprenorphine) also needs to be dispensed safely
and as a result supervised consumption schemes have been set up all over the
country.
People new to treatment or those whose drug use becomes chaotic will be asked to
go on supervised consumption to help them stabilise and ensure they are taking the
right dose. People already on treatment may be asked to have supervision if there is
a risk of their medication falling into the wrong hands.
Where will I get my Methadone or Subutex?
Your keyworker or prescriber will arrange for a Pharmacy to provide the service. A
take-home dose will be issued for Sunday on Saturday and at Bank Holidays. It is
helpful to arrange a regular time to attend the Pharmacy and talk through how
supervision will happen in advance.
What do I do if I experience difficulties?
Discuss this with your keyworker or prescriber who will help you.
How long will I have to do this for?
The Department of Health recommends 3 months to begin with.This will be adjusted
to your individual situation.What might be suitable for one person may not be right
for another.Your keyworker will assess your progress and discuss arrangements with
you.
Substance
Guidelines
SubstanceMisuse
Misuse
Guidelines
59
59
60
60
Substance
MisuseGuidelines
Guidelines
Substance
Misuse
6. Blood Borne Viruses
61
BLOOD BORNE VIRUSES
It is well known that substance misusers run a high risk of contracting blood borne viruses especially
injectors. These are Hepatitis C (up to 70% of local injectors), HIV and Hepatitis A & B. Most of this
section refers to Hepatitis C which is now the commonest cause for Liver transplant in the USA and 30%
of cases in Europe. Treatment with Ribivarin and pegylated Interferon is available for moderate liver
disease with good results although side-effects can be significant. Our Hepatologist Dr Matthew Cramp
has treated over 60 patients to date.
Hepatitis C Virus Natural History
100 cases
Chronic
Progressive
hepatitis
liver disease
80
Cirrhosis
40
Death
30
?10
Non-progressive liver
disease
30-40
“Recovery”
Normal life
expectancy
0
5-10
TIME (years)
15-30
20-40
General Medical Services play a vital role in addressing:
◆ reduction of the risk of contracting or transmitting infection (safe injecting, prescribing, needle
exchanges, safe sex etc.)
◆ contraception
◆ testing/diagnosis with pre and post-test counselling
◆ referral and monitoring of positive cases
◆ immunisation against Hepatitis A and B for those at risk from co-infection
◆ advice on use of medication and alcohol
Aims of Pre-test Counselling
1. Enable a client to make an informed decision about whether to be tested or not
2. Provide an opportunity to discuss routes of transmission
3. Discuss the implications and support needs that may follow a positive result
4. Explore harm reduction practices to minimise the risk of infection in the future
Some patients will much prefer to take their own samples which makes sense so provide
clean equipment and assist as needed.
62
Aims of Post-test Counselling
1. Give test results verbally and in writing as soon as possible whether negative or positive
2. If positive – Provide information on the disease.
– Provide information about further diagnostic tests and examinations.
– Arrange a follow up appointment with the Hepatology Department
or GUM clinic (for HIV)
3. If negative – Provide further harm reduction advice
Specialist support can be arranged with:
Amanda Clements Hepatology Nurse Specialist at Derriford Hospital Tel: 01752 517665
[email protected]
Maureen Bromage at the Eddystone Trust Tel: 01752 257077
www.britishliver trust.org.uk
www.drugs.gov.uk/hepcguide.htm
www.doh.gov.uk/hepatitisc/briefing.htm
There is currently a Blood Borne Virus Nurse
Clare Meachin, Blood Borne Virus Nurse at Derriford Hospital Tel: 01752 517670 or 07659 589704.
• To improve the availablility and uptake of the Hepatitis B vaccine amongst clients most at risk in the
Plymouth area
• To improve the availability and uptake of Hepatitis C testing
The targeted client group are those who do not access health provision and health care through the usual
routes, those who may not have a GP, those who are homeless or in temporary accommodation and
those who are at most risk, e.g. injecting drug users, sex workers and men who have sex with men.
As well as vaccination, the aim will be to opportunistically and contextually offer Health Education with
regards to Hepatitis B and Hepatitis C; and harm minimisation concentrating on safer injecting and sexual
behaviours.
At each visit there is an opportunity for a brief intervention, and the following areas will be assessed and
evaluated:
• Knowledge of Hepatitis B
• Knowledge of Hepatitis C
• Understanding of the vaccination programme, and why it is important
• Knowledge of safer injecting practices
• Condition of injecting sites
• Knowledge of safer sexual practices
63
HEPATITIS A & B
VACCINATION
You probably don’t like needles
GPs or Practice Nurses are able to vaccinate and claim for this
service for those at risk. Peter Joliffe’s letter explains the Red Book
details below.
Recently a 10 year old boy came for testing having stood on his
father’s used needle - father being Hep C positive – so think families
regarding Hep B vaccine programmes.
As yet there is no HCV vaccine and Dr Magda Metzner is undertaking
research into HCV negative injectors as a way of exploring this
further.
Dear Charlie
Where drug users employ needles in their habit or gain income through
providing sexual services they should be defined as at high risk of Hepatitis B
and it is a Terms of Service requirement for their GP, having identified that
they are at risk because of their lifestyle, to offer them protection from
Hepatitis B and to ensure it is provided if they wish it. There is no Item of
Service payment for this if the practice provides it themselves (they can of
course refer the patient into secondary care but very few do) but some funds
can be reclaimed if the practice supply the vaccine through the “Personally
administered item” system.
Hepatitis A is different. Drug and alcohol users are more at risk of Hep A than
non-abusers and should be offered the chance to be protected again as a
matter of a GPs Terms of Service. If they accept and the GP provides it, then
the GP is paid an “Item of Service B fee” (currently £6.80) and can gain extra
income if they provide and dispense the vaccine through through the
“Personally administered item” system.
There is no compunction for a GP to perform vaccination for Hep A or B
themselves for this indication but many do rather than refer (this is perhaps
because of the varying quality of secondary care services available to such
patients around the country). Para 12 (2) (c) states that a GP shall comply by:
“(c) offering to patients, where appropriate, vaccination or immunisation
against measles, mumps, rubella, pertussis, poliomyelitis, diphtheria and
tetanus;” Hepatitis is not mentioned.
However it is recommended that the service is provided in house if possible.
Regards
Peter Joliffe
Devon LMC Secretary
64
7. Specialist Areas
65
PREGNANCY
Pregnancy requires all women to make changes in their lifestyle, and for the pregnant drug user there is
even more pressure to make positive changes.
Pregnancy can act as a trigger for the woman to have flash backs about past experiences and feelings. In
particular memories of significant childhood abuse, sexual assault or rape as an adult may become issues.
At a time when she needs to stabilise her drug use for the sake of the unborn baby, these feelings can
create a big challenge of sticking to a script and not using on top. A trusting and honest relationship with
her drug worker, midwife and prescriber is crucial to making the most of the experience and retaining
her in a treatment package.
Not all women who misuse drugs will make bad parents
All pregnant drug users fear that their baby will be taken away
Of course some unborn babies are the subject of major concerns from the Social
Services and are very occasionally removed at birth. The majority of babies return to
their natural family after birth. A positive and supportive emphasis in the pregnancy
hopes to reduce child protection issues later.
If not already involved then once referred a drug worker will be arranged as a
priority. Support will be available from:
• Emma Smith
– Harbour CPN
• Avril Archibald &
Julie Reynolds
– Midwife
• Reka Shrestha
– Obstetrician
• Adrian Houston
– Social Worker
• Jo Strawbridge
– Family Support Worker
Jasmine Clinic
Special ANC for drug using mums
Every Thursday late morning
66
At Presentation
BE SUPPORTIVE and BUILD A RAPPORT
– confirm pregnancy
(refer for termination if appropriate)
– start Folic Acid
– arrange urine drug screen
KEEP DRUG USE STEADY - NO RAPID CHANGES
DON’T STOP ANTI-DEPRESSANTS or PSYCHIATRIC MEDICATION ABRUPTLY
• refer to specialist antenatal clinic
• refer for prescribing or advice as necessary
During the pregnancy
• Nutrition
may need supplements
anti-emetics particularly with methadone
constipation more common
• Blood tests
HIV, Hep B & C particularly relevant with an injecting history
if positive refer as appropriate
commence Hep B vaccination if antigen positive
specialist venepuncture available at hospital ANC
DON’T TRY TAKING BLOOD IF NOT CONFIDENT OF SUCCESS
some patients may prefer to take their own blood which makes sense so just
provide the clean equipment and assist as needed
• Routine Care
at GP surgery if possible
• Special issues
advice on affects of all drugs on fetus - Derriford Information Pharmacist very
helpful
Breast Feeding
– Please encourage this as another opportunity for the baby’s health to help motivate the Mum to
look after her own
– Chaotic drug users will rule themselves out
– Certain antidepressants need caution or dose adjustments
– HIV positive is a contra-indication
67
SECONDARY CARE
for complex needs
If a GP considers a patient’s substance use related needs to be beyond their experience,they are advised
to refer to the local specialist services. General health care needs (GMS) will continue to be managed at
the practice which is the same entitlement of any NHS patient as outlined in the DoH Orange Guidelines
published in 1999.
Complex issues may include:
• Chaotic users
• Dual diagnosis - addiction & mental illness
• Substantial requirement for psychotherapy or advocacy
• High dose and complex prescriptions
• Diamorphine scripts
• Dexamphetamine initiation
• Injectable scripts
• Complex legal or social needs
• Cultural or ethnic needs
• Complex medical needs - HIV, STD, hepatitis etc.
DUAL DIAGNOSIS
This is a potentially misleading phrase even though it is fashionable. It has come to apply to psychiatric
patients who also use drugs and alcohol. Within the service however it means the co-occurrence of
psychiatric symptoms with a substance misuse problem. It should not be forgotten that complex comorbidity also includes drug-related and other physical illnesses that may effect someone’s mental state.
Psychiatric problems may be present before the substance misuse, result from it or simply occur at the
same time. These patients have a higher than average incidence of mood disorder and psychosis which
may be acute or long-term.They also have a higher incidence of suicide hence it is essential to pay careful
attention to the psychological state of substance misusers and in contrast the substance misuse history
of psychiatric patients. Either group often self medicate.
Sedatives like alcohol, benzodiazepines and opiates may be used as emotional painkillers and can be
perceived as helpful by people with physical pain of non-physiological origin. Stopping them sees a
rebound of psychological symptoms and so continued drug use occurs.
Stimulants give Dutch courage and amphetamine is an excellent antidepressant whilst
others reduce appetite. Be careful to look for underlying depression and eating disorders in
this group who risk rebound of depression on stopping.
Continued and excessive use of stimulants can cause psychosis while cessation of sedatives can unmask
a psychosis.The latter is seen briefly with fragile personality structure (often termed personality disorder)
or PTSD when sedatives are suddenly removed.
68
History taking should include:
• Full substance misuse history
• History of personality prior to misuse
• History of mood/personality during misuse
• Present mental state
• Assessment of risk - especially impulsivity and suicidality
• History of self-harm - cutting, excess needle use, overdose, eating disorder & lack of risk awareness
There is no point in trying to treat any of the above if drug use is chaotic.
The use of psychotropic medication is likely to increase risk and if in doubt seek Specialist assessment
from the new Enhanced Care Team (previously this service occurred at CDS). New plans are underway
to link the Adult Mental Health Services into the process as at times the patient is best treated by them
and at times there is a need for joint working.
Initial treatment steps are:
1. Stabilise substance misuse with a substitute script where appropriate
2. Detox from alcohol or short-term drug misuse
3. Reassess mental state and begin other treatment or refer as appropriate
4. If stability not possible then refer to Enhanced Care Team
Clearly GPs are advised to work closely with either keyworker or CPN colleagues. Once stability is
established many cases can return to GP care but there is a hard core group of clients that require longterm specialist input.
SPECIALIST DRUG SERVICE – SDS
Tel: 01752 763109
SDS is a 4 bedded unit situated within the Glenbourne Acute Psychiatric Unit on Bridford Ward.
This inpatient service is available to drug users (18 years and over) whose long-term goal is abstinence.
Treatment includes detoxification, planned respite, stabilisation/reduction of prescribed medication and
crisis intervention. A harm reduction philosophy is also followed.
The staff of 5 are led by Senior Drug Worker Cindy Fitzpatrick in conjunction with Dr Alison Battersby.
The unit makes its own decisions over admissions and discharges with stays typically lasting 6 to 8 weeks.
Referrals are considered from any Harbour Team at a weekly meeting.
69
The Criminal Justice System
It is estimated that a high proportion of the criminal population are regularly using drugs hence the
interest in alternative approaches by the Courts as listed below.The ultimate aim of the Probation Service
that oversees this, is to minimise the level of risk to both the public and the offender themselves.
Drug Treatment and Testing Order (DTTO)
Following successful pilots under Judge Taylor in Plymouth this Order was introduced in 1998. The user
is kept out of prison with conditions covering drug testing and attendance for treatment. Currently the
CDS are contracted for a set number of hours per week to work on the individual’s drugs issues and do
weekly oral fluid drug tests. Most also receive scripts for treatment via a team of four keyworkers.
Targeted Police Referral (TPR)
This scheme is aimed at offenders involved in acquisitive crime or dealing who are targets for the Police.
Proactively they make referrals of such people whereby the client signs an agreement for the TPR workers
to make contact with them.
They are then offered an appointment and have the opportunity to become involved in treatment. No
information at all is fed back to the Police unless specifically requested by the client. 3 Keyworkers and a
Prescriber run this service.
Funding is from the Police and a joint referral meeting occurs every 2 weeks.
Community Rehabilitation Order (CRO)
Previously called a Probation Order, a CRO is imposed when custody is not deemed appropriate but it
is felt that an offender merits supervision in the community.Within this category there are 3 methods of
tackling a drug problem:
a) A referral to Addaction, a national drug and alcohol agency who offer brief interventions which
predominately provide advice and guidance. Addaction staff are based in the Probation office. They
cannot prescribe although they frequently act as a conduit to other agencies and GPs.
b) The Probation Officer may initiate a referral to the drugs services themselves or contact GPs for
assistance.
c) The offender may have to attend a program such as: Alcohol and Substance Related Offending (ASRO)
or Drink Impaired Driving (DIDS)
Combination Order
As a CRO with a number of hours of unpaid community work attached.
Actual Release Licence (ARL)
This covers early release from prison under a number of conditions.
For example, the offender may have an electronic tag placed on their ankle in order to ensure they remain
at their place of residence at night.This is known as a Home Detention Curfew (HDC). If conditions are
broken return to prison may be swift.Within this order drugs issues will be addressed in the same manner
as with a CRO.
The Prison Service and Post Release Work
Currently no maintenance treatment is available in local prisons (despite high use) and users are given a
Lofexidine detox on arrival. Drugs work in prisons is carried out by C.A.R.A.T.s teams. This stands for
Counselling, Assessment, Referral, Aftercare and Throughcare.
Funds are being sought to provide new posts linking prison and community treatments.
70
CONTROLLED DRUGS IN GENERAL PRACTICE
Safe custody
Drugs must be kept in a locked receptacle to prevent unauthorised access.
A locked GP bag in a locked place such as a car boot is the best defence bearing in mind injectables may
denature in extreme temperatures in a car.
CD Registers
To be kept by all practices as a bound volume (not loose leaf) kept on site
Each class of drug on a separate page and specified at the top of the page
Entries in ink and in chronological order - any corrections by dated note in margin
Entries to be made no later than next day of issue/use
Record date received, from whom, amount and form (tabs, amps etc.)
Record date supplied, to whom, amount,form, who administered it & rolling stock balance
Doctors should keep a bound book in emergency bags to record details & batch numbers
Registers to be kept for 2 years from last date entry
Locums/Non principals keep own Registers
Destruction
1. Stock CDs
These can only be destroyed in the presence of a Police Officer, Health Authority Medical or
Pharmaceutical Advisors or Home Office & Police Inspectors
2. CDs returned by patients/their representatives
Drugs received should be recorded – date, patient’s name, drug name/dose/form amount
Destruction should be witnessed and two dated signatures record the event
Pharmacists and Dentists are similarly empowered.
ON NO ACCOUNT SHOULD SUCH RETURNS
STOCK THE DOCTOR’S BAG OR TREATMENT ROOMS
71
Drugs and the Law
Drug Classification
The Misuse of Drugs Act 1971 places drugs into 3 categories
Class A
Cocaine, heroin, morphine, codeine, methadone, dipipanone (Diconal), pethidine, LSD, ecstasy, psilocybin
(“magic mushrooms”), cannibinol (“hash oil”) Some of these drugs can be possessed if you have a
prescription to do so
Class B
Amphetamines (sulphate and base), dexamphetamine (Dexedrine), methylamphetamine (Ritalin), DFII8
(Dihydrocodeine), cannabis (resin and herbal). If any of these drugs are prepared for injection then they
become Class A.
Class C
Anabolic steroids, Temazepam. It is not illegal to possess tranquillisers but it is illegal to supply them to
another person. From January 1996 the law changed with regard to Temazepam. It is now illegal to
possess Temazepam without a prescription.
The Government say that Cannabis will be reclassified to Class C at some point in the future.
Sentencing
CLASS A
CLASS B
CLASS C
Possession
7 yrs
5 yrs
2 yrs
Trafficking
LIFE
14yrs
5 yrs
With possession it is accepted that the drugs were for personal use and found in your house, car, hand
or pocket.
It is not against the law to see someone using drugs.
You can legally dispose of a controlled drug to avoid it being used by flushing it down a toilet. A teacher
or parent may do this ideally with a witness.
Trafficking may involve:
◆ possession with intent to supply
◆ supply of drugs - including for no profit
◆ production of controlled drugs without licence
◆ drug use & supply on premises - parents, youth workers, club owners etc. have responsibility to prevent
this
As with all offences, the sentence will also depend upon individual circumstances.
72
Ear Acupuncture and
Complimentary Therapies
Auricular Acupuncture has been used as an adjunct in treating drug users since the 1970’s when it was
developed in The Bronx in New York.There are over 200 acupuncture points on the ear and by chance
it was found that a combination of 5 were effective in relieving withdrawal symptoms in users. This is a
simple and cheap treatment, which can be help at any stage of treatment or rehabilitation. It is widely used
across the UK.
Auricular acupuncture reduces stress, withdrawals and anxiety, helping service users to co-operate in
treatment and engage with services. It is very popular with clients and is effective for withdrawal from all
drugs.
An auricular acupuncture service is currently being set up at Hamoaze House for users of all city services.
Other recommended therapies are massage, aromotherapy, homeopathy, body acupuncture, nutritional
supplements and herbal teas.We hope some of these will be available in the future.
COCA recommend complementary therapies as the best way of helping users of Crack Cocaine.
New service set up by Dr Mary Embleton now available Monday to Friday at Hamoaze House:
73
Reducing Drug Related Deaths
Guidance Based on the National Treatment Agency Guidelines
There is inevitability that taking illicit drugs is inherently dangerous and the level of risk is directly
related to the substance used, the individual, where and how it is used and the location where the use
takes place. It is clear that removing all risk from drug use is impossible. However, it is essential that
for people who come in to contact with treatment services every effort is taken to reduce the risk
associated with their use.
The Department of Health action plan identified that a 20% reduction in drug related deaths would result
in 300 lives saved nationally per year. It was also noted that whilst the number of immediate drug related
deaths can be fairly readily recorded, the identification of those related to long term causes such as blood
borne viruses are harder to predict, as they may appear decades after the drug use has finished.
Key areas identified to reduce drug related deaths are as follows:
• Provision of sterile injecting equipment, including injecting paraphernalia. This should be made available
in line with the recommendations of the Advisory Council on the Misuse of Drugs.
• Outlets for injecting equipment should be community based and consideration should be provided
towards mobile distribution for high risk groups.
• A range of disposal facilities should be available for safe disposal of injecting equipment.
• Information should be available on blood borne viruses and blood testing for viral status should be
readily available to users, and vaccination for hepatitis A&B with appropriate protocols should be in
place.
• All professionals in contact with drug users should be aware and able to provide information on the
care of medical complications from drug use, e.g. DVT, Endocarditis, abscesses, ulcers, pulmonary
embolism, etc
Reducing Drug Related Deaths (Surrounding Prescribed Medication)
Prescribing of maintenance or detox medication for treatment of substance misuse should be the
preserve of community drug services or trained GPs with the support of a specialist drugs worker.
All prescriptions must be within the terms of the Drug Misuse and Dependency Guidelines3.
Circumstances that are not covered by these guidelines must be under direction of the community
drug service and involve discussion with a multi-disciplinary team, including a GP with Special Interest
and Consultant input.
• Supervised consumption should be carried out for all new prescriptions and in other circumstances
where there is evidence of continuing instability or risk of diverted supply.
• Prescriptions should be monitored carefully for a degree of illicit use. When a prescription is initiated
it is to be expected but continued illicit use is to be taken seriously especially if alcohol is a factor.
• It is important that a balance of harm reduction against risk is made by the multi-disciplinary team
bearing in mind that a common factor in overdose deaths is unsatisfactory cessation of a treatment
episode and premature exit from a treatment programme.
• It is important that an assessment is made of a client’s ability to store medication safely in order to
minimise the risk of accidental overdose in opiate naive people, particularly if children are in the
house.
74
• The awareness of risk factors of overdose should be taken into account by professionals in contact
with drug misusers in order that high risk situations can be identified and pre-empted. These would
include:
– History of non-fatal overdose
– High levels of use with or without intoxication
– High concurrent levels of alcohol use
– Situations in which the tolerance of the individual has been changed i.e. after detoxification or
release from prison
– Concurrent mental health problems
– History of polydrug use
– Other evidence of high risk behaviours
– Recent cessation of contact with drug treatment services following an unsuccessful treatment
episode
Specific Mortality Factors Related to Different Drugs Used
Stimulant Drugs including Ecstasy
There are a number of high risk factors specific to use of this type of drug as follows:
• Excessive use
• Concurrent alcohol misuse especially with Cocaine
• Hot environments
• Increased aggression and violence, leading to injury or death
• Cardiac problems
– studies from America show that ≤25% of heart attacks in the 18-45 age group are related to cocaine
use especially in the first hour after use.
• Cerebrovascular Incidents
• Viagra
Crack Cocaine
Specific risks associated with crack include:
• Pulmonary Oedema
• Pulmonary Haemorrhage
• Pulmonary Barotrauma
• Inhalation of Foreign Bodies from pipe apparatus
• ‘Crack-Lung’ Syndrome - cough, shortness of breath, inflammation of the lungs and high temperature
Opiates
The main risk of death from opiates is respiratory depression following overdose. This is particularly
relevant if the person’s tolerance has changed due to a period of abstinence. Other deaths around
opiate use are usually related to complications following the risk of infection through poor injecting
practices.
75
Benzodiazepines
The Benzodiazepine group of drugs alone is unlikely to cause death however it should be noted that
the concurrent use with opiates and/or alcohol greatly increases the risk of death, due to the
potentiation associated with these combinations.
Hallucinogenic Drugs
There are few recorded fatalities due to the use of hallucinogenic drugs, although stories of people
attempting to fly from high buildings whilst using apocryphal may have an occasional basis in fact.
References
1. Preventing Overdose Guidance for Drugs Actions teams on Providing Resuscitation
Drug Users. Department of Health, 2002.
Training
for
2. Reducing Drug Related Deaths. The Advisory Council on the Misuse of Drugs, 2000.
3. Drugs Misuse and Dependency: Guidelines on Clinical Management. Department of Health, 1999.
This summary has been based upon the following document:
Reducing Drug Related Deaths: Guidance for Drug Treatment Providers.
National Treatment Agency, 2004.
76
8. Service Overview
Substance
Guidelines
SubstanceMisuse
Misuse
Guidelines
77
77
SERVICE OVERVIEW
This is the hardest section to write in these guidelines due to its complex nature so please forgive any
omissions that occur for the sake of keeping things simple.
The scene is busy as this table illustrates:
The Many Stakeholders
Criminal
Justice
City
Council
Prisons
Probation
Police
Housing
NHS
Social
Services
(Psychiatry)
SDS-4 Beds
CDS
DTTO
CAS
GPs
Hepatology
Pharmacies
SMAT
Voluntary
Sector
AA, NA,
Broadreach
Harbour Centre
Needle Exchange
TPR
Young Peoples Service
User & Carer Group
Eddystone Trust
Hamoaze House
Working Links
Trevi House
In October 2003 after nearly 3 years of protracted negotiations Plymouth’s separate treatment services
merged into one organisation called Harbour. Both the Harbour Centre and CDS have been operating
for over 15 years in the City so this represents a historic event toward collaborative working as statutory
and voluntary providers join forces.
Harbour
The Integrated Service bringing together:
CDS - Community Drug Service
CAS - Community Alcohol Service
The Harbour Centre
SMAT - Substance Misuse Assessment Team
TEAM
Primary Care
Secondary Care
SMAT
Criminal Justice (DTTO & TPR)
Young People Service
Needle Exchange
Management, Administration &
Education and Training
LOCATION
Ermington Tce
Ermington Tce
Ermington Tce
Damerel Hse
YES, Union St
Ermington Tce
Hyde Park House
LEAD
Steve Mills
Kathy Parker
Kathy Parker
Kim Murray
Richard Kirkup
Tony Pattinson
Tony Faragher
CONTACT
Key
No.
Workers
314221
10
314220
5
314222
6
314231
7
314222
4
314196
2
314276
Primary Care
Less complex cases with GP prescribing
Secondary Care
More complex/psychiatric cases with in-house prescribing
Criminal Justice
Police or Court Referrals
Young People
Often self-referred under 18 years
78
The CDS always had in-house prescribers through their Consultant Psychiatrist and medical team whilst
the Harbour Centre depended upon local GPs to prescribe particularly Hugh Campbell. A state of
gridlock gradual developed with 1 to 2 year waiting lists blocking any new patients entering treatment.
This was compounded when several GPs decided not to prescribe following LMC advice in the late 1990’s
after some negative experiences in the Coroner’s Court nationally, so saturating CDS prescribing.
Interestingly there were 2 exceptions to the above namely Freedom HC and St.Levan Surgery. Here, by
different methods, a surgery based service had developed allowing the GP to work alongside a
counsellor/drugworker rather like the arrangement for Midwives and Health Visitors.This approach was
popular all round for the following reasons:
• easy access to local service
• less stigma for patients/clients
• less bureaucracy - letters, faxes, and the dreaded ansafone!
• better support for GPs and Pharmacies
• better support for the drugworker as part of the PHCT
• personal so self-regulating waiting lists
As the service has been restructured the new Primary Care Team has built off this successful approach
and located surgery based workers into 18 active practices who have attended local training. To date 56
out of 160 GPs have attended a 2 day training event which represents 28 out of 47 practices.
ACCESS TO A TRAINED GP BY POPULATION GROUPS
Waterfront (98,163)
67%
Tamar (70,603)
62%
Riverside (84,727)
39%
PLYMOUTH
57%
This indicates a healthy Primary Care activity level since the bulk of the problematic drug using
community seeking treatment live in the Waterfront, St.Budeaux or North Prospect neighbourhoods.
Readers may be interested to see a caseload analysis from CDS/Harbour Centre broken down by
practice as of November 2002:
Active Cases Waiting List
CDS
237
Harbour Centre 134
135
48
79
Further analysis revealed that 48% of the clients come from the
following practices:
We now call these the “Big 7” and they have sent 20 out of a
possible 23 GPs on the new local training. So they are a pretty
dedicated bunch and are a priority for support.
No. of Patients
Freedom Health Centre
86
North Road West
36
St. Budeaux
35
St. Levan
36
Waterloo
17
West Hoe
34
Wycliffe
21
Specialist Medical Team
A collaborative approach has been developed incorporating the two paradigms of primary and secondary
care working alongside each other. Regular peer supervision and joint case reviews are the backbone of
our system which aims to generate the most appropriate care packages for patients, joined up clinical
leadership driving safe clinical practice and an accessible resource for referrers.
Consultant Psychiatrist
We welcome Dr Alison Battersby who arrived in October 2003 following Dr Anne Read’s retirement.
Alison is the lead doctor within the Secondary Care Team and has taken over responsibility for the 4 SDS
in-patient beds in the Glenbourne. It is hoped to recruit a second consultant in due course with particular
interest in alcohol.
GPwSI (GP with Special Interest)
Plymouth tPCT now employs 4 GPs in this capacity with varying responsibilities indicated in this table:
Sessions pw
Dr Barrie Blackstone
5
DTTO
Dr Hugh Campbell
2
Primary Care (City East)
Dr Mary Embleton
1
Primary Care (City West)
Dr Charlie Lowe
6
Primary Care (Outer City)
TPR,YPS & Diamorphine
Primary Care GPwSI activity is focused upon providing a prescribing service for patients whose GPs do
not prescribe.They are also available to participating GPs for consultancy with complex cases and taking
over more specialised scripts. Within the new GP Contract the GPwSIs amongst others will take
responsibility for visiting practices annually to support their Clinical or Service Governance and act as a
conduit for good practice standards.
80
Derriford Hospital
Bearing in mind the limited training that has been available around substance misuse for non-specialized
health and social care workers it is no surprise that at times strange prescribing habits and/or referral
requests can emanate from the hospital sector.We are endeavouring to build better links with training to
ensure better communication and where appropriate accessible referral pathways. This represents an
important piece of work for the DAAT.
Common pitfalls are the sudden request to take over a prescription for say methadone on the day of
discharge leaving no time to secure safe arrangements let alone a care plan. It is also not particularly fair
for patients on our current waiting list who are committed to getting treatment to have their places
hijacked by a drug user who happens to be in hospital but may not be very committed to getting
treatment. Involuntary treatment of addictive problems is rarely successful and can hoover up many
valuable resources. There is often an issue around the anxiety staff have in witnessing a self-destructive
process which then can prompt a drive to get a patient treated. Sadly a patient may not be able or be
motivated to address their dependency at one particular time though it never does any harm to
encourage and supply information about where to seek help in the future. Please do not create unrealistic
expectations for the Advice & Information Desk at Ermington Terrace.
A special plea on prescribing from hospital is to avoid using benzodiazepines if at all possible and if
absolutely necessary only to issue small quantities. These are highly addictive substances and research
shows their disinhibiting effects can be counterproductive to recovery from anxiety provoking
experiences.The brain is effectively blanked leading to a failure in the development of coping responses.
Anxiety is a normal part of life’s experience and benzo dependents - at what ever age - are prone to
greater risk taking resulting in accidents, violence or health compromising activities.
81
BROADREACH HOUSE
Broadreach House off the Tesco Roundabout at Roborough is a registered charity, which offers treatment
services for men and women who suffer from alcohol or drug dependence. Referrals can be accepted
from Health or Social Service professionals anywhere in the UK, as well as self-referral.
The organisation owns and manages three separate residential centres:
Broadreach (01752 790000) is a registered nursing home with 36 beds. Clients are able to undertake
a medically supervised detoxification during their 6-week programme of treatment, which includes a
two-week Newcomers Programme based on motivational psychology.
Longreach (01752 348348) is a care home and has 20 beds for women only. It offers both short-term
treatment and long-term rehabilitation packages for up to 6 months.
Closereach (01752 788699) has 17 beds for men only, and offers long-term rehabilitation programmes
of 3-6 months.
Broadreach House also offers an Aftercare and Resettlement services in line with its commitment to
providing continuing care.These ensure that vulnerable clients are equipped to cope with re-integration
into the community.
In accordance with Broadreach House policy of employing evidence-based interventions, an entirely new
approach has been designed in the past year. It draws on the strengths of Motivational Interviewing and
Cognitive Behavioural Therapy.
Broadreach House training courses reflect this shift in philosophy, offering a range of short courses
specialising in Motivational Interviewing and a one-year diploma course in Addictions Counselling.
CONTACT www.broadreach-house.org.uk
TREVI HOUSE
Tel: 01752 255758
Trevi House is a rehabilitation project for women who have drug and alcohol problems accompanied by
their children age 0-8 years. It is anticipated that a full rehabilitation programme would last for at least 69 months.
The project is funded by a negotiated service contract purchased in compliance with Services under
Community Care Act Provisions. Referrals are made by Drug Agencies, Social Services or self-referrals.
The project and buildings are registered with the National Care Commission and limited to a maximum
of 12 mothers and 16 children.
What is Trevi?
Togetherness is the essence of TREVI HOUSE. It is the only facility of its kind in this country, which
provides residential rehabilitation for mother and child together in a home environment.
Rehabilitation begins and continues with a respect for the individual. Lifestyle appraisal and recognition of
the changes to be made.
Education can offer a personal choice. It can include parenting, physical fitness, career training, leisure and
creative activity.
Values is precisely that. Making and achieving personal goals and thereby giving value to your life.
Independence means choice, self-reliance, liberty, self-esteem and autonomy.
All the above opportunities are available for those women who have a strong desire to change their
lifestyle and achieve a better, more independent, life for themselves and their children in the community.
82
HAMOAZE HOUSE
Tel: 01752 566100
A day centre to promote independence and a drug free lifestyle.
Hamoaze House is a former Port Admiral’s residence situated at the end of George Street in Devonport.
Last autumn it begin accepting referrals for its innovative day programme which was not aimed to just
provide social activity but a springboard to promote personal responsibility for a new beginning. Apart
from group therapy a range of other therapeutic activities are appearing including music technology,
football coaching, a gym, an outdoor play area and a nursery facility.Weekly support for family members
or “affected others” is provided.There is a strong preventative focus to the work. Particular attention is
given to Young People and those trapped in the offending cycle.
Referrals are taken from agencies, self-referrals or GPs. Individual timetables are developed. Attendance
on the programme is dependent on clients being drug free or on prescribed medication only.
PLYMOUTH EDDYSTONE TRUST
Tel: 01752 257077
The Eddystone Trust is an independent organisation providing information, training and support for
anyone affected by HIV / AIDS and Hepatitis C.
A dedicated Hepatitis C worker - Maureen Bromage - is available to provide 1:1 support / information
regarding Hepatitis C both to professionals and anyone affected by the virus.
At Eddystone a wide variety of information and support is available including:
• pre / post test discussion,
• information on healthy living
• and practical support.
Specifically tailored training packages can be made available to community and other groups, along with
our own Hepatitis C training package.
We have a strict confidentiality policy, ensuring that no information will be passed outside the trust
without a client’s prior consent.There is also a branch in Torbay.
83
WORKING LINKS
Progress2work
* A New Direction
Progress2work (p2w) is an innovative project supporting people who have had a problem with drug
misuse in the past, but who are now ready to consider work, training or education.
You know how hard it can be for ex-users to get their lives back on track - even once the first crucial
step to stay clean has been taken. P2w is here to help people take the next step.
* Specialists at getting people into work
We focus on addressing individual needs and barriers to getting back to work and have already helped
3,000 local people into jobs, over 1,000 of these have participated in progress2work.
Employment Zone
Another option has recently become available to people who have experienced problems with drugs or
alcohol, early entry to the Employment Zone. Like p2w, there is individual support to help people achieve
realistic goals, and funding may be available to help with essentials for starting a new job.
We can offer:
• Confidential, one-to-one advice
• The latest vacancies and how to apply
• Links to the best quality provision
• On-going support in your new job
It’s easy!
The Employment Zone and progress2work operate across Plymouth. If you want to find out how to take
the next step you can call us on:
Freephone 0800 917 9262
Or (01752) 672007
Email: [email protected]
Working Links, 64-66 Ebrington Street, Plymouth, PL4 9AQ
Working Links, 21 Victoria Road, St. Budeaux, Plymouth, PL5 1RW
www.workinglinks.co.uk
84
9. Monitoring and Records
85
NATIONAL DRUG TREATMENT
MONITORING SYSTEM – NDTMS
This scheme replaced the Regional Drug Misuse Databases on 1 April 2001 to inform central government
policy. The number of problem drug users presenting for treatment to drug treatment agencies and GPs
in England is collected together with the number still in treatment on the 31 March annually.
Results for 2001/02 indicate:
◆ an 8% increase with a total of 71,306 presentations
◆ 73% indicated Heroin use
◆ 35% are < 25 years of age
◆ referrals – 42% self-refer, 16% by GPs, 17% by Criminal Justice
Interpretation of the results requires
awareness of the system’s limitations
for example the lack of available
treatments will result in an underreporting of crack users.
Any GP working with drug users
without support from a drug
treatment agency needs to
submit a Client Contact Form
since regional funding is
dependent
upon
accurate
activity returns to the NDTMS.
Key Workers will routinely complete
the forms.
86
RECORDS
Purpose designed cards for paper based
records or expensive bespoke software do
exist for substance misuse work. EMIS have
developed a module but due to lack of
demand this has not been released yet. The
CDS use “Advantage” for automated
prescribing and this costs around £4000 to
install per site. It offers a reliable scripting
system with audit and reporting.
The computer database systems at all 4
parts of the Integrated Service are operated
for administrative purposes with no clinical
staff at present entering clinical data
directly. So for example the services are
unable to say how many clients on their books have Hepatitis C at
present.
Copies of the Plymouth Management Card (see inside back cover) are available from Charlie Lowe. It
operates rather like the old Maternity cards collecting all the key information together including
prescription repeats.
CHRISTO INVENTORY for
SUBSTANCE MISUSE SERVICES (CISS)
Dr George Christo a Psychologist from the Royal Free in London has developed this easy to use
evaluation tool that has been accepted across the agencies in Plymouth for assessing treatment outcomes.
Essentially a client is scored across the following 10 domains:
• Social Functioning
• General Health
• Sexual/injecting risk behaviour
• Psychological
• Occupation
• Criminal Involvement
• Drug/alcohol use
• Ongoing support
• Compliance
• Working Relationship
Each domain is scored for problem severity 0 = none, 1 = moderate and 2 = severe. A score of 0
indicates no problems and the maximum score of 20 severe problems. It takes about 3 minutes to
complete and does not necessarily require the client to be present. Comparisons across practices or
services over time are possible.
87
Tips on interpreting CISS items
• All injectors score at least 1 on ‘sexual/injecting risk’. Some alcohol users when disinhibited have been
known to have unsafe sex with casual partners.
• Child care is an ‘occupation’ (you decide if full or part time)
• Irregular petty crime (eg. shoplifting) scores 1 on ‘criminal involvement’ unless it occurs on a regular
basis (eg. 2+ times per week), in which case it scores 2. Any instances of a more serious crime (eg.
violence) scores 2 regardless.
• All methadone or benzodiazepine prescribed (scripted) clients score at least 1 on ‘drug use’, score 2
if using other drugs on top. Only drug free clients score 0.
• Alcohol users who regularly binge still score 2 on ‘drug use’ even if they do not drink daily.
• Prescribed medication drugs like anti-depressants or neuroleptics need not to be classified as ‘drug
use’. Prescribed abusable drugs like Methadone, Benzodiazepines or Dexedrine are classified as drug
use.
• Clinic attendance classifies as ‘ongoing support’. All clients should score 1 or less, unless they were
assessed at intake for the month before coming to the clinic.
• ‘Working relationships’ for clients with a lot of external professional involvement or issues (eg. lawyers
or childcare and social services, reports that need writing) are unusually time consuming. They score
2 even if the client is not stressful to see.
For harm minimisation prescribing based service
Average CISS score = 9.1 (sd=3.4)
CISS scores in range 0 to 5 = low problem severity
CISS scores in range 6 to 12 = average problem severity
CISS scores in range 13 to 20 = high problem severity
For outpatient alcohol service
Average CISS score = 8.1 (sd=3.4)
CISS scores in range 0 to 4 = low problem severity
CISS scores in range 5 to 11 = average problem severity
CISS scores in range 12 to 20 = high problem severity
For abstinence orientated treatment
A CISS cut-off score of 6 or less can be used to indicate ‘good outcome’ for abstinence based treatments.
SEE APPENDIX FOR FULL CHRISTO INVENTORY
RESEARCH
A research interest group has started meeting every one to two months at Hamoaze House.
Local projects at present include investigation into Hepatitis C infection and Urine Screening on long
term Benzodiazepine scripts in the elderly.
88
10.Training and
Clinical/Service Governance
89
TRAINING
Since October 2001 seven 2/3 day training programmes have been run offering the first ever local
education for GPs and similarly four evening training programmes have made connection with 70
Pharmacy staff.
Previously learning was on the hoof with negligible preparation from Undergraduate courses or GP
Vocational Training Schemes. It is hardly a surprise to find that two main camps developed - those that
had somehow worked out for themselves a way of working with users and those whose unpleasant
experiences with users had put them off this work completely. In 2000 the LMC recommended GPs stop
prescribing after the arrest of a Carlisle GP following a methadone overdose. Dr Charlie Daniels rightly
stated that four requirements must be met:
• training
• adequate support
• reimbursement
• supervised consumption.
This agenda has largely driven developments here over the last 18 months and the list is fortunately now
close to being fully addressed. Trained GPs are now receiving £125 every 6 months for prescribing
methadone, buprenorphine or dexamphetamine for a user. This will increase to £365 p.a. per eligible
patient with a £500 annual retainer per practice under the new proposed LES.
This guide is evidence of the particular skills involved in working with addictive problems and it is
encouraging to see that the Plymouth tPCT has put so much support into correcting our training deficit
by completely funding all courses to date.The initial training (as recommended by the Orange Book for
GPs) is of course just a beginning and we are now looking at ways of providing further training
opportunities.Various ideas are under discussion such as a bimonthly evening lecture programme, joint
sessions between small groups of Surgery Receptionists and Pharmacy Technicians who work nearby, halfday sessions on certain topics like Hep C or Motivational Interviewing, books/CD-ROMs and a
Newsletter. Please feed back your preferences.
Liz Roberts of Britannia has kindly purchased a few copies of the useful book:
Care of drug users in general practice, edited by Berry Beaumont
second edition 2004, Radcliffe Publishing
and the CD ROM reference by SCODA:
SHARED CARE, SHARED LEARNING
Please contact Charlie Lowe to borrow these.
Clearly each individual will choose how best to address their own learning needs.The
Critical Review on page 5 provides a record of ongoing learning which can be added to
anyone’s portfolio.
2/3 day initial training will be an ongoing twice yearly event for new GPs moving into Plymouth.
Other national initiatives are available such as the Certificate Course run by the Royal College of General
Practitioners - open to Nurses and Pharmacists too. For details contact Hugh Campbell.
90
CLINICAL/SERVICE GOVERNANCE
“A framework through which organisations are accountable for continuously improving the quality of
their services and safe-guarding high standards of care by creating an environment in which excellence in
care will flourish”
So nothing too complicated!
Russ Hayton in his new role as Clinical Governance Manager at the DAAT will be taking a lead in this
area. He will be focusing on effectiveness around evidence-based practice, supported staff and
organisational structure. This will cover issues from guidelines to training to communications to
monitoring and evaluation.
Central to quality care are issues such as:
– effective team working
– a service that responds to users needs
– good communication between all those involved in care
Significant incident reviews (these can be positive or negative), and reviews of complaints can be a useful
way of advertising and improving the above, particularly if ways can be found to involve all players in the
review process. We are hoping in the future to be able to produce and circulate comparative data and
show examples of ‘good practice’. Hopefully these will stimulate thought, discussion and service
improvements.
Hugh Campbell a pioneering local GP in this field has already been looking into this area at his practice.
His initial focus is on the following areas:
• Disease register - drug & alcohol dependency, mental illness, Hep C
• Notification of Regional Database recall system
• Prescribing audits - benzodiazepine use, methadone dosage
• Introduction of Christo Scores
Clearly this is a new and evolving field for which a local strategy needs to be developed.
91
92
11. Appendices
93
94
95
Chlordiazepoxide (Librium)
Regime for Detoxification from Alcohol
Name.....................................................................................................................................................................................
Date .......................................................................................................................................................................................
Start Date.............................................................................................................................................................................
Chlordiazepoxide 10mg Tablets
Vit B1 (Thiamine) Tablets Daily
DAY
DATE
MORNING
LUNCHTIME
AFTERNOON
NIGHT
1
2
3
4
5
6
7
8
9
10
96
Christo Inventory for Substance Misuse Services
Name ___________________________________ DOB _________________ DATE _______________
This form is for evaluation / clinical audit purposes only and is a rough indicator of professional impression of recent drug /
alcohol related problems in the past month. Specific situations / behaviours are listed only as guiding examples and may not
reflect the exact situations / behaviours of the client. (Please ring a number under each heading).
Social
0 ...
1 ...
2 ...
functioning
e.g. client has a stable place to live and supportive friends or relatives who are drug / alcohol free.
e.g. client’s living situation may not be stable ... or they may associate with drug users / heavy drinkers ... (Tick one).
e.g. living situation not stable, and they either claim to have no friends or their friends are drug users / heavy drinkers.
General health
0 ...
e.g. client has reported no significant health problems.
1 ...
moderate health problems, e.g. teeth / sleep problems, occasional stomach pain, collapsed vein, asymptomatic
hep B / C / HIV.
2 ...
major health problems, e.g. extreme weight loss, jaundice, abscesses / infections, coughing up blood, fever, overdoses,
blackouts , seizures, significant memory loss, neurological damage , HIV symptoms.
Sexual
0 ...
1 ...
2 ...
/ injecting risk behaviour
e.g. client claims not to inject, or have unsafe sex (except in monogamous relationship with longstanding partner, ).
e.g. may admit to occasional ‘unsafe’ sexual encounters, or suspected to be injecting but denies sharing equipment.
e.g. client may admit to regular ‘unsafe sexual encounters, or has recently been injecting and sharing equipment.
Psychological
0 ...
e.g. client appears well adjusted and relatively satisfied with the way their life is going.
1 ...
e.g. client may have low esteem, general anxiety, poor sleep, may be unhappy or dissatisfied with their lot.
2 ...
client has neurotic disorder e.g. panic attacks, phobias, OCD, bulimia, recently attempted or seriously considered
suicide, self-harm, overdose or may be clinically depressed. Or client may have psychotic disorders, paranoia (e.g.
everybody is plotting against them), deluded beliefs or hallucinations (e.g. hearing voices).
Occupation
0 ...
client is in full time occupation e.g. homemaker, parent, employed or student.
1 ...
e.g. client has some part time parenting, occupation or voluntary work.
2 ...
e.g. client is largely unoccupied with any socially acceptable pastime.
Criminal involvement
0 ...
e.g. no criminal involvement (apart from possible possession of illicit drugs for personal use).
1 ...
e.g. client suspected of irregular criminal involvement, perhaps petty fraud, petty theft, drunk driving, small scale dealing.
2 ...
e.g. suspected of regular criminal involvement, or breaking and entering, car theft, robbery, violence, assault.
Drug / alcohol use
0 ...
e.g. no recent drug / alcohol use.
1 ...
e.g. client suspected of periodic drug / alcohol use, or else may be socially using drugs that are not considered a
problem, or may be on prescribed drugs but not supplementing from other sources.
2 ...
e.g. client suspected of bingeing or regular drug / alcohol use.
Ongoing support
0 ...
e.g. regular attendance of AA / NA, drug free drop centre, day centre, counselling, or treatment aftercare.
1 ...
e.g. patchy attendance i.e. less than once a week contact with at least one of the above.
2 ...
e.g. client not known to be using any type of structured support.
Compliance
0 ...
e.g. attends all appointments and meetings on time, follows suggestions, or complies with treatment requirements.
1 ...
e.g. not very reliable, or may have been reported as having an ‘attitude’ problem or other difficulty with staff.
2 ...
e.g. chaotic, may have left treatment against staff advice or been ejected for non-compliance, e.g. drug use, attitude
problem.
Working relationship
0 ...
relatively easy going e.g. interviews easily, not time consuming or stressful to work with.
1 ...
moderately challenging e.g. a bit demanding or time consuming, but not excessively so.
2 ...
quite challenging, e.g. very demanding, hard work, time consuming, emotionally draining or stressful to see.
CISS Total Score =
© 1998 George Christo PhD, PsychD.
97
Alcohol Audit
1. How often do you have a drink containing alcohol?
Never ❑
Monthly or ❑
2 to 4 times ❑
2 to 3 times ❑
Less
a month
a week
(0)
(1)
(2)
(3)
4 or more ❑
times a week
(4)
2. How many drinks of alcohol do you have on a typical day when you are drinking?
1 or 2 ❑
3 or 4 ❑
5 or 6 ❑
7 to 9 ❑
10 or more ❑
(0)
(1)
(2)
(3)
(4)
3. How often do you have six or more drinks on one occasion?
Never ❑
Less than ❑
Monthly ❑
Weekly ❑
Monthly
(0)
(1)
(2)
(3)
Daily or ❑
almost daily
(4)
4. How often during the last year were you unable to stop drinking once you have
started?
Never ❑
Less than ❑
Monthly ❑
Weekly ❑
Daily or ❑
Monthly
almost daily
(0)
(1)
(2)
(3)
(4)
5. How often during the last year did you fail to do what was normally
you because of drinking?
Never ❑
Less than ❑
Monthly ❑
Weekly ❑
Monthly
(0)
(1)
(2)
(3)
expected from
Daily or ❑
almost daily
(4)
6. How often during the last year have you needed a first drink in the morning to get
yourself going after a heavy drinking session?
Never ❑
Less than ❑
Monthly ❑
Weekly ❑
Daily or ❑
Monthly
almost daily
(0)
(1)
(2)
(3)
(4)
7. How often during the last year have you had a feeling of guilt or remorse after
drinking?
Never ❑
Less than ❑
Monthly ❑
Weekly ❑
Daily or ❑
Monthly
almost daily
(0)
(1)
(2)
(3)
(4)
8. How often during the last year have you been able to remember what happened the
night before because you had been drinking?
Never ❑
Less than ❑
Monthly ❑
Weekly ❑
Daily or ❑
Monthly
almost daily
(0)
(1)
(2)
(3)
(4)
9. Have you or someone else been injured as a result of your drinking?
No ❑
Yes, but not in the last year ❑
Yes, during the last year ❑
(0)
(2)
(4)
10. Has a relative or friend, or doctor or other health professional been concerned about
your drinking or suggest you cut down?
No ❑
Yes, but not in the last year ❑
Yes, during the last year ❑
(0)
(2)
(4)
98
Scoring
• Questions 1-3 total: male scoring > 4 or female scoring > 3 indicative of potential hazardous alcohol
consumption.
• Questions 4-6 total: male or female scoring > 4 indicative that there may be a level of dependency.
• All questions total: male or female scoring > 8 indicative of potential hazardous alcohol consumption.
• All questions total: male or female scoring < 8 indicative of consumption within safe limits.
99
Specialist Service
Opioid Withdrawal Scales
Objective Scale - clinician assessed
Objectives
Absent/Normal
Mild-moderate
Severe
Lactorrhoea
Absent
Eyes Watery
Eyes streaming/wiping eyes
Rhinorrhea
Absent
Sniffing
Profuse secretion
(wiping nose)
Agitation
Absent
Fidgeting
Can’t remain seated
Perspiration
Absent
Clammy skin
Beads of sweat
Piloerection
Absent
Barely palpable hairs
Readily palpable
standing upvisible
Pulse rate
< 80
> 80 but < 100
> 100
Vomiting
Absent
Absent
Present
Shivering
Absent
Absent
Present
Yawning / 10 min
<3
3-5
6 or more
Mydriasis
Normal <4mm
Dilated 4-6mm
Widely dilated >6mm
100
USEFUL CONTACT NUMBERS
Drug Agencies
• Harbour
Main Reception (Primary, Secondary, SMAT & NX) ................................................314222
Fax: 314188
Damerel House (Criminal Justice - DTTO & TPR) ................................................314321
Fax: 314230
Hyde Park House (Management & EAT) ..................................................................314276
Fax: 314277
Young Peoples Service at YES ........................................................................................314222
Fax: 206629
• Broadreach House
• Trevi House
..........................................................................................................................................255758
• Hamoaze House
• Addaction
..............................................................................................................................790000
..................................................................................................................................566100
............................................................................................................................................827600
• Narcotics Anonymous
..........................................................................................................07071 224017
• Alcoholics Anonymous ..............................................................................................................0845 7697555
HIV/Hep C Support
• Amanda Clements ..............................................................................................................................517665
Hepatitis Nurse Specialist at Derriford Hospital
• The Eddystone Trust
..........................................................................................................................257077
Employment Advice and Guidance
• Progress2work ....................................................................................................................................361515
A project assisting clients in recovery to access training or employment opportunities. Run by Working Links.
• Working Links
....................................................................................................................................673030
Assistance to long term unemployed and socially disadvantaged.
Criminal Justice
• Devon and Cornwall Probation Service
......................................................................................827500
101
Domestic Violence
• Women’s Refuge
................................................................................................................................562286
• Devon & Cornwall Police Domestic Violence Unit
• Victim Support
....................................................................720501
....................................................................................................................................777118
Day centre for Homeless and Vulnerable People
• Shekinah Mission
................................................................................................................................203480
A range of assistance for those in crisis such as cheap meals, accommodation assistance and life skills.
Housing
• Plymouth Access To Housing ( P.A.T.H. ) ........................................................................................255889
Advice and guidance on issues such as raising a deposit, debt consolidation and tenancy law including
a one night only stay for Rough Sleepers at Gates.
• Supporting People - Alan Hocking ..................................................................................................306276
PCC Windsor House
Advice on all council housing matters such as exchanges and waiting lists. Chair of D.R.A.G. panel which
considers priority housing requests for those in recovery.
• The Homeless Unit ............................................................................................................................304063
Emergency housing provision for Plymouth residents of no fixed abode.
• Stonham Housing ................................................................................................................................226605
A number of properties which offer support to vulnerable people with a key worker facility.
• The Bruised Reed Trust ....................................................................................................................265597
Run a dry house in Plymouth.
• The Ship Hostel
..................................................................................................................................225974
• The Salvation Army Hostel
102
..............................................................................................................562170

Contents

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