Transcript Holistic Care for Homeless Drug Users

Specialist Homeless and
Primary Care Perspective
Dr Nigel Hewett
Leicester Homeless Primary Health
Care Service.
Dawn Centre LE2 0JN
GP and PCT Clinical Lead for Drugs
and Alcohol
We are at the same point now with
regard to alcohol treatment services
as we were 15-20 years ago with
drug treatment services.
The Leicester Homeless Death List.
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Male, 27, cause of death not listed.
Male, 42, alcoholic found dead in
disused house.
Male, 46, found dead in ditch,
depression and alcoholism.
Male, 44, burned to death in
disused house.
Male, 44, status asthmaticus.
Male, 34, hepatic renal and
pulmonary failure due to
paracetamol poisoning and that he
did kill himself by taking an
overdose.
Male, 41coronary thrombosis
(diabetes and self neglect.
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Male, 30, methadone poisoning,
having purchased a bottle of
methadone he ingested and
caused his own death.
Male, 53, acute alcohol poisoning
(found dead on a bench)
Female, 18, inhalation of butane
gas.
Male, 39, acute haemorrhagic
pancreatitis.
Male, 27, hypothermia and high
blood levels of diazepam.
Male, 57, Alcoholic, epilepsy.
The Leicester Homeless Death List.
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Male, 34, haematemesis due to
alcoholic liver disease.
Male, 20, dihydrocodeine
poisoning.
Male, 41, methadone, cyclizine and
diazepam poisoning.
Male, 36, morphine poisoning
following heroin injection.
Male, 42, acute left ventricular
failure due to coronary atheroma.
Male, 28, fatal heroin overdose.
Male, 17, methadone toxicity.
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Male, 23, multiorgan failure, heroin
misuse. Male, 22, acute methadone
poisoning, found in bin shed, Dover
Street. Male, 22, heroin OD, found in
toilet in Oxford. Male, 74, myocardial
infarction due to ischaemic heart
disease due to smoking. Male, 31,
heroin overdose with alcohol in night
shelter. Male, 51, acute left ventricular
failure due to coronary atheroma
(chronic alcoholic). Male, 45, collapsed
and died outside night shelter,
bronchopneumonia, cirrhosis, chronic
alcohol abuse. Male, 42, septic shock,
bronchopneumonia, hiv infection,
chronic alcoholic. Male 43, stabbed to
death. Male, 29, acute pulmonary
oedema. Male, 31, heroin addict,
alcoholic.
The Leicester Homeless Death List.
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Female, 36, bronchopneumonia due to
self neglect. Male, 34, picked up by
police taken to lri where died. Male, 21,
Fatal misuse of heroin. Male, 26, heroin
od, Male, 29, heroin poisoning. Male,
43, L pneumonia, alcoholic liver disease.
Male, 36, drug and alcohol intoxication,
found dead in ns. Male, 43, Pulmonary
oedema, alcohol and codeine excess.
Male, 39, HepC positive, chronic
alcoholic, heroin od. Male, 29,
suspension by ligature – suicide in
prison.
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The average age at death for
these 114 patients is 41
years.
Alcohol is implicated as a
cause of death for 45%.
Accidental overdose of drugs
of abuse is implicated as a
cause of death for 28%.
Deliberate suicide is
implicated for 7%.
Summary 2000 to 2005.
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PMS pilot established
Outreach service now covers
five direct access hostels,
night shelter & two drop-ins.
1107 patients registered in
last year.
8680 Doctor and nurse
consultations.
Contraception services
enhanced to include condom
provision.
80% cervical cytology rate.
Acupuncture treatment for
musculoskeletal conditions
introduced.
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Vaccination rates increased,
e.g. 136 patients vaccinated
against hepB.
96 treatments for heroin
dependence commenced.
RCGP audit awarded highest
possible grade of
“outstanding” for our
treatment programme for
drug misuse in primary care.
Clinical care enhanced by
significant event analysis,
audits of standards of care,
prescribing trends and
mortality data.
Homeless Primary Care Drug Treatment
in Leicester Today.
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Full time drug worker since 2004
Continue to accept chaotic alcohol and poly drug using,
groin injecting, dual diagnosis patients without waiting list.
Flexible drop-in service, within clear boundaries.
Audits – 2004, 85% had 3 doses hepB vaccine
2004, methadone audit dose range 30ml to 140ml,
average maximum dose 72ml
2005 shared care introduced, numbers in treatment
increased from average 31, to 59.
06/07 73 patients treated in 98 treatment episodes
81% retention rate at 12 weeks
100% screened for blood borne viruses.
07/08 85% retention rate, average maintenance dose
67ml, 92.2% vaccinated against hepatitis A and B
Non medical prescribing & extended
role of drug worker.
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Non-medical prescribing introduced in 2007, now
used for majority of patients (currently 61 out of
63)
Minor illness treatment, blood testing,
vaccinations all directly provided by drug worker,
supported by primary care team
Active involvement in inter-agency care, chairing
single homeless MDT
Community alcohol detoxification protocol for
drug patients with alcohol dependence
Homeless Community Detox Protocol
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If there is an immediate, urgent need for detoxification in this client group- such as vomiting, acute
jaundice, haematemesis or other severe physical health problems, or symptoms of Delerium
Tremens, then in-patient treatment as a medical emergency is the only safe option
There is also some evidence that repeated cycles of abrupt withdrawal and relapse may increase
the risk of fits with subsequent withdrawal episodes – so a failed detox may be worse than no
detox at all. Repeated failed detoxes may also reinforce the expectation of treatment failure, and
reduce the possibility of successful engagement in the future.
However, we are frequently consulting with chaotic and damaged
patients who are desperate to overcome their alcohol dependence.
They are able to access our drop-in based service, but are too
chaotic to engage with appointment based secondary care alcohol
services. Many patients present in the early stages of withdrawal,
having decided themselves to attempt to withdraw, without
medical support if necessary. It is also important to consider that
there is no risk free option, the average age at death for homeless
patients in Leicester is 41 with nearly half of all deaths in this
group attributed to alcohol. Consequently, not intervening leaves
the patient at continuing high risk of death.
Audit of Community Alcohol
Detoxification for Homeless Patients
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All 19 patients treated in 12 months June 07 to
July 08 to allow for 6 month outcome assessment
Age range 28 to 55, average 40, 2 F, 17 M.
47% had SADQ score recorded (majority had
dosage regime decided on clinical assessment)
Of those recorded, 33% had SADQ score in
moderate range (15-30)
And 66% had SADQ score in severe or very
severe range (31-60)
Alcohol Detox Outcomes
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12 (63%) had Pabrinex (B vitamin IM injections)
12 of 19 (74%) completed 8 day course
3 (16%) remained continuously dry
1 immediately lost to follow up, of remaining 15
average duration to relapse 34 days, range 2 to
120 days.
6 month outcome 8 (42%) dry (3 continuous plus
5 dry again after relapse)
Another 3 significantly reduced consumption, 5
the same, 3 lost to follow up.
So at 6 months 11 (58%) significant
improvement
Near Future
Full time primary care based alcohol
worker for homeless people starting 09/10
 Hospital employed alcohol liaison specialist
nurse -in place now, most posted
anticipated
 Community alcohol liaison worker (Comm.
Alcohol Team post) recruitment soon
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Not so near future
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Lets acknowledge the reality that most patients do not fit
into tidy categories of drug dependence or alcohol
dependence
The majority of the cases we see have poly substance
misuse issues and usually accompanying mental and
physical illness.
Has to be holistic response (addressing physical and mental
health as well as substances) - primary care is the only
setting trained and experienced to provide this
Aspire to GP facilitated, primary care based substance
misuse service. Substance misuse worker in every practice
willing to address not just drugs and alcohol, but drugs or
alcohol in primary care setting