Transcript Glasgow Addiction Services

Kennedy Roberts
Senior Medical Officer and Clinical Lead North Cluster
Glasgow Addiction Services Community Addiction
Teams
What are the challenges for drug
prescribing services?
Scottish Drugs Forum
28th Feb 2007
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What are the challenges for the
service user?
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Accessibility
Engagement
Retention in treatment
Effective outcome for service user and
clinician subjectively as well as
objectively
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Royal College of General Practitioners (Scotland)
Not so Surprising News!
For many current IDVU’s there
are multiple contraindications
to therapy.
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Clinical Guidelines on the management of Hepatitis C
Booth et al
GUT 2001
Some patients on oral methadone and particularly
those individuals who are committed to
rehabilitation programmes
may be
considered for treatment
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Clinical Guidelines on the management of Hepatitis C
Booth et al
GUT 2001
Or is that
MAYBE?
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Surprising News!
Studies have shown that IDU’s current , former and relapsing do
just as well in treatment for HCV as non users.
This is in terms of:
Retention in treatment.
Clearance of the virus.
(Also low rates of subsequent reinfection)
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Here are some of them!
Backmund M, Meyer K et al Hepatology 2001
Cournot M, Gilbert A, et al Gastroenterology Clin Biol
2004
Dalgard O, Bjoro K, et al Eur Addict Res 2002
( 5 years follow up )
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Here are some more of them!
Interferon alpha therapy for hepatitis C:
Treatment completion and response rates among
patients with substance use disorders.
Substance Abuse treatment, Prevention and Policy (
U.S.) Published 12/01/2007
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There are no drug services currently integrated with
hepatology/gastroenterology clinics.
But we have some managed clinical networks
We do have plans to look at this:
Hepatitis C Action Plan for Scotland_
The Testing, Treatment Care and Support Working Group
are well aware of the changing view of treating IDU
infected with HCV- Needs Assessment is being carried
out
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Coal face Issues
Service users may be using for 1 to
4 years before presentation:
Issues for education ( Probably need to start at the
primary school)
Issues for NDX
Issues for outreach.
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Coal face Issues
Alcohol primary and secondary
Co-morbidity.
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Coal face Issues
Where are the rest of the 50,000?
Who is best placed to:
identify?
engage?
test?
treat- managed clinical network
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Case Study 1
Female patient born Jan 1971
Fairly typical history of drug misuse starting early teens
Little alcohol involved initially mainly cannabis,
“recreational” drugs, benzodiazepines and opioids
1st IV use aged 18
Various interventions from 22 when first attended
specialist service.
First substantial period of abstinence from 25 years to 28
years of age on methadone prescription
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Case Study 1
28 years of age alcohol “social drinking” pubs only
31 problematic drinking at home usually vodka.
Average consumption 1 litre / day vodka.
32 required “eye opener”
33 ( Jan 2004) first alcohol detox. Residential ( suspicion
of previous convulsion related to
benzodiazepine/alcohol withdrawal)
Rapid relapse to alcohol, became jaundiced, admitted
medical ward( May 2004), presence of alcoholic liver
disease and oesophageal varices noted.HCV diagnosed.
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Case Study 1
May to Nov 2004 continued illicit drug free but return to
alcohol.Approxiamtely half to whole bottle vodka daily.
Methadone reduced to 55mgs daily by this time.
19th November 2004 re-referred to medical clinic deeply
jaundiced.
Diagnosis alcohol related cirrhosis.
26th Nov 2004 died.
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Case Study 2
Female patient born 1972
Problematic alcohol use at 12 years of age
Daily alcohol use to intoxication several days a week at
14 years
Alcohol dependency 16 years
16-18 use of benzodiazepines and buprenorphine
18 First IV use of buprenorphine
19 First IV use of heroin
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Case Study 2
Female patient born 1972
25-28 reasonable period of abstinence on methadone
28 to 33 unstable, in and out of methadone treatment
33 Returned to full engagement with services,
methadone dose max. 110 mgs currently on 80 mgs
Past 2 years alcohol more and more of a problem
This year in patient alcohol detox. Relapsed and
currently waiting for urgent reassessment ( to-morrow)
With view to further detox.
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Case Study 2
Female patient born 1972
Recent admission to medical ward.
GI bleed.(still awaiting more results)
HCV diagnosed PCR positive.
Liver function tests disturbed alcohol/HCV
Management!
Prognosis?
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