Transcript Good Prescribing to support Criminal Justice Interventions

Good Prescribing
to support Criminal Justice
Interventions
Lucy Cockayne
Consultant Psychiatrist
Lead Clinician
NHS Fife Addiction Service
Structure of the session
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Introduction (5 minutes)
Overview of prescribing principles (20 minutes)
Small group scenarios (10 minutes)
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Prisoner release planning
The doctor won’t prescribe diazepam
Continued use “on top”
Cocaine and methadone
A client smelling of alcohol
Feedback (5 minutes)
Introduction –
What are the main issues?
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Are there Common Principles to non forensic
treatment?
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Are there differences in practice?
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Write down your top 3
Write down 3 differences
Why do these occur? Are these good
differences or not?
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Group discussion
What are the aims of good
prescribing in a forensic setting?
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Alleviate suffering
Reduce harm associated with drug use
Reduce criminal behaviour
Reduce complications of drug misuse
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Reduce risk of BBV transmission
Complications of injecting
General health
Promote recovery
Specific Challenges
1. For Prison Prescribing
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Continuity of prescription
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from the community
Back into the community
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Volume of potential clients and their speed of
movement through the system
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Tension of depth vs speed of assessment
Response to drug related death data
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Especially for short termers
Issues around loss of tolerance
Cost and staffing
2. Community criminal justice
prescribing
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Tensions within the team
Differing opinions
Expectations from court
Treatment as more than a prescription!
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“First do no harm”
“More than methadone”
What forms of drug misuse have
evidence based prescribing options?
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Opiates
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Benzodiazepines?
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Methadone
Buprenorphine
Actually no licensed prescribing- controversy over
structured detoxification
Alcohol
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Detoxification
Acamprosate, naltrexone and antabuse as adjunct to
abstinence
Alcohol Treatments
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Detoxification
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Chlordiazepoxide (Librium)
Vitamin supplementation
Aids to maintaining abstinence or controlled
drinking
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Antabuse (abstinence only)
Acamprosate
Naltrexone
Treatments exist:- Average alcohol
intake (drinks / week, TLFB) –but
they’re not a “cure”
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Opiate dependence
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Four treatment types:
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Agonist
eg methadone
Antagonist eg naltrexone
Partial agonist eg buprenorphine
Symptomatic eg lofexidine
Think lightbulbs! 100w vs 60w vs dead!
Lightbulbs…
Agonists
Heroin
Methadone
x
Partial
agonist
Antagonist
(Blocker)
x
x
Buprenorphine
(Subutex, Suboxone)
Naltrexone
x
WHY NOT JUST METHADONE?
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“If the only tool you own is a hammer, everything
starts to look like a nail”
Choice increases retention in treatment
Choice increases patient “buy in”
Different patients need different treatment
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Some want sedative effects
Some need to be clear minded
Some are at higher risk of overdose
Some need to avoid drug interaction or side effects
Prescribing for complications of
substance misuse
Important to help progress through treatment and
prevent relapse
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Up to 40% have mental health needs that may
benefit from prescribing
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Physical health problems common
Current barriers to good quality
treatment in forensic settings
1. Organisation factors
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Stigma
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Unrealistic expectations and false beliefs…
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Confusion between getting addicted and treating
addiction and its consequences –ie cause and effect
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Lack of flexibility
2. Patient factors in prescribing
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“Motivation”?
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Compliance
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Severe dependence
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Complex issues
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Memory problems
There is no single, one
“best” treatment for ever
and ever
the best treatment is the
one that suits the client at
that time
Where does medication fit in the
treatment programme?
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House theory of addiction
medication fills in the foundations.
 Foundations come first
 Foundations are only the start…
 Foundations must be strong
 Changes in foundations may have
catastrophic effects.
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“Drug addiction is a chronic,
relapsing brain disease”
Benzos also cause more subtle problems:-
Why is it so hard to detoxify from
benzodiazepines?
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Not usually aware of mild intoxication
Amnesia
Physically hard
Behaviourally hard
We underestimate how much impact it has on
the brain…
GABA BRAIN CIRCUITRY
60 - 75% OF
ALL BRAIN
SYNAPSES
ARE
GABAERGIC
Treatment of benzodiazepine
dependence
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Gradual withdrawal –regimen will depend on
pattern of dependence and length of
dependence – can take years…
NO proven role for “substitute prescribing”
Possibly use of flumazanil in future to help
withdrawal.
Small Groups and Feedback
Prisoner release planning
 The doctor won’t prescribe diazepam
 Continued use “on top”
 Cocaine and methadone
 A client smelling of alcohol
Please summarise the MAIN concern and give
ONE take home message from the group!
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Some men
see things as
they are, and
say “why?”
I dream of
things that
have never
been, and
say “why
not?”
Robert F Kennedy