Transcript Nelson Alcohol and Other Drug Service

Nelson Alcohol and Other Drug
Service
GP CME Presentation
March 2009
What do the AOD clinic do?
• Specialist assessment of alcohol and other drug disorders
• Comprehensive assessment and diagnosis using DSM1V
criteria
• Addiction medicine specialists
• Use of specific pharmacotherapy
• Co-existing disorder management
• Therapeutic interventions
• Family/whanau support
• Specific Youth service
• Detox service
• Opioid substitution programme
• GP Liaison for opioid substitution via GPs
• Education
• Research
What drugs are most commonly
used?
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Nicotine
Alcohol
Cannabis
Stimulants
Benzodiazepines
Opiates
Hallucinogens
Solvents/gasses
What is Detox?
“Detoxification refers to the process by
which the effects of opiate drugs are
eliminated from opiate dependent users
in a safe and effective manner, such
that withdrawal symptoms are
minimised. (WHO 2006)
“The history of the treatment of narcotic
withdrawal is a long and dishonourable one....”
Kleber H.D. et.al. The treatment of Narcotic withdrawal: A Historical Review. J Clin
Psych. 43:6(Sec 2)- June 1982
• Belladonna
treatments
• Peptization and
water Balance
Treatments
• Bromide sleep
treatment
• Lipoid Treatments
• Endocrine
treatments
• Immunity
Treatments
• Accupunture
• Vitamin C
•Abrupt and rapid withdrawal
•Convulsive therapy
•Hibernation therapy
•Methadone
•Phenothiazines
•Diphenoxylate
•Propanalol
•Proxyphene
•Naloxone precipitated
withdrawal
Opiate Withdrawal Management
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Buprenorphine v traditional ‘cold turkey’
Symptomatic relief
COWS done daily
Management of the most difficult to deal
with symptoms. Insomnia, restless legs,
agitation
• Protracted withdrawal syndrome
Protracted Withdrawal?
• “While the literature would support the
continuation of physical and subjective
abnormalities beyond the acute
withdrawal period of alcohol and
opiates....protracted withdrawal has not
been conclusively demonstrated
because of methodological limitations”
Satel SL et.al. Should protracted withdrawal from drugs be included in
DSM IV? AM J Psych. 150:695-704,1993.
Choice of opiate agonist
• Both methadone and buprenorphine have
been found to be effective in the treatment of
opiate withdrawal though the evidence for
methadone has a greater research base
• There is evidence that buprenorphine has a
shorter period of withdrawal and a greater
rate of retention in treatment.
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[1] Gowing L, Ali, R, White, J. Buprenorphine for the management of opioid
withdrawal. Cochrane database of systematic reviews 2006. Issue 2
[2] Amato et.al. Methadone at tapered doses for the management of opiate
withdrawal (Review) Cochrane database of systematic reviews 2005, issue
three.
Detox Outcomes
Smyth et.al.
In-patient treatment of opiate dependence: medium term follow-up
outcomes.
British Journal of Psychiatry. (2005), 187, 360-365.
• 149 patients admitted to an inpatient detoxification
• Detoxification/individual therapy/group therapy
• 2-3 years later 5 died
• 54%continuing to use illicit drugs
• 57% on maintenance
• 25% abstinent within last month
• Abstinence associated with
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completion of in-patient program
attendance at aftercare
not using IV
absence of family history of using
Table 6:
Number of clients receiving opioid substitution treatment in New Zealand via
Specialist Services (n = 18)
Services/DHB
Auckland
Christchurch
Wellington
Nelson/Malborough
Otago
Midcentral
Waikato
Northland
Taranaki
Napier Hawkes Bay
Wanganui
Tauranga
Wairarapa
Southland
Timaru
Lakes DHB
West Coast DHB
Tairawhiti
Total
Total
(n = 4400)
1089
565
374
338
317
305
289
215
140
123
113
107
91
91
81
69
63
30
Specialist Service
(n = 3463)
809
334
306
265
282
266
260
177
103
95
87
102
85
81
64
67
51
29
GP Authority
(n = 932)
280
231
68
73
35
39
29
38
37
28
26
5
6
10
17
2
12
1
4400
3463
937
Daryle Deering et al. NAC ‘Barriers to
Care- A Service Users Perspective’ 2008
% GP Authority
26
40
18
22
11
13
10
18
26
23
23
5
7
11
21
3
19
3
21%
Barriers To Transfer Of
Clients-Primary Care
All 18 services identified barriers
• GP availability
(61%)
• Stigma
(39%)
• Cost to clients
(66%)
• Clients preferring clinic
(39%)
• Clients not ready
(39%)
• Service staffing/attitude related
(44%)
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Deering et al 2008
GP liaison for methadone
prescribing
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Criteria for GP prescribing
Process for transfer
Ongoing monitoring
Responsibility of care
What happens when the wheels fall off?
Criteria for GP prescribing
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No concerns re behaviour
No unresolved issues re misuse
Illicit drug use not detected in UDS
Client has complied to requirements of
O.S.T.P.
No recent illegal activities
Client has engaged with participating GP
Stable dosage of methadone
Takeaway arrangements established
Process for transfer
• Contact with client’s G.P.
• Authorisation by AOD Medical Officer
• Client’s comprehensive assessment
and prescribing details to G.P.
• Copy of medical history and risk factor
assessment sent to G.P.
Ongoing monitoring
• Client to attend G.P. appointment once
monthly for renewal of prescription.
• G.P. Liaison Clinician to meet with client
at least annually.
• AOD will ask client for 2 urine drug
screens a year
• G.P. Liaison Clinician liaises with client’s
G.P. throughout treatment.
Responsibility of care
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Overall stability of client
Injection site(s) examination
Hepatitis status
Liver function tests
HIV tests
What happens when the wheels fall
off?
• Clients can be returned to Specialist
Service
• G.P. Liaison Clinician is available
Monday to Friday 0830 to 1700 hours
• Relevant clinical staff available if
required.
Who to Contact at AOD
Methadone Prescribing:
Jude Burgess or Dr Lorraine Balance
Detox/withdrawal:
Steph Anderson
Complex AOD/Pain/Out of hours:
Dr Lee Nixon or Dr Marijke Boers
Regional Service Manager is Eileen Varley