Transcript Prescribing for young people

Prescribing for young people
• What the literature has to say
• hype’s prescribing process
• hype young people’s experience
Prescribing for young people
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Evidence
Criteria
Consent and competency
Aims of treatment
Principles of good practice
Prescribing
Assessment
Community Detox Service
Information for referrers
The above service was started in January 2003 for young people aged up to 18
who were looking for a rapid withdrawal with a view to abstinence.
Referrals Criteria
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Young people who have expressed a desire for a rapid detox from opiates.
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Young people on 30mg or less of methadone.
Exclusions
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Medical or psychiatric history that would indicate community detox as a risk to physical or mental health.
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Young people with a history of drug induced psychosis.
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Young people with a current active alcohol dependence.
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Young people with a history of violent or abusive behaviour towards staff.
Referrals Process
GPs: Referrals should be made in the usual way. It would be helpful if the referral letter was headed as a “Referral for Detox”. Agencies: Please
complete the hype Community Detox Service Referral Form and either fax or mail it to us. Copies can be obtained from hype if you don’t already
have one.
Detox assessment
We aim to offer appointments within a week of receipt of referral by the Detox Service. The Detox Assessment process would normally take 2-4
appointments over two weeks to complete. This will focus on exploring motivation for change, physical and mental fitness and the social supports
available to the young person. There will also be an exploration of previous detox experiences and the reasons behind relapses. This will help the
young person to use these experiences as useful learning tools in identifying areas of vulnerability to relapse and promote self-awareness in relation
to their addiction recovery.
Preparation
From the information gathered at the assessment stage, ways in which to best support the detox process will be identified with the patient. This
process will include palliative care to minimise physical withdrawals, ways in which to self-monitor and looking at identifying relapse cues and
triggers.
Strategies for cues and trigger avoidance will be discussed. The emphasis will be on the young person taking responsibility
for the detox by way of exercises designed to promote cognitive restructuring and self-awareness. Practicalities such as
medication regimes and appointments will also be organised at this time. Supporting relatives or others will have the
opportunity to be included at this stage, with the young person’s consent, for advice and support regarding their role in the
detox.
Detox
The detox method will be identified with the young person at the detox assessment stage and although medication regimes
may differ, the level of psychosocial support is the same. The young person will be seen daily for the first two weeks
(excluding Saturday and Sunday). Advice and support will be offered throughout on the management and monitoring of
withdrawal symptoms, as well as continued focus on relapse prevention. The young person will be encouraged to refer to
the strategies identified in the assessment and planning stages to help with cravings and cue/trigger avoidance. The
effectiveness of these will be monitored. Staff will liaise with relevant medical colleagues regarding any adjustments to
medication regimes and random urine testing will be carried out to monitor detox authenticity.
Relapse prevention
The young person will be offered the opportunity to commence opiate blocking medication to protect their abstinence. The
consumption of this medication should be supervised by a supportive other and in order for this to begin, the young person
must remain opiate free for a minimum of seven days. In addition, the young person will be offered time limited individual
relapse prevention sessions. This will be for ten sessions, one per week, each focusing on a particular aspect and addressing
difficulties as they arise.
Follow Up/ aftercare
Many young people wish to cut their link with drug services following detox or relapse prevention and as part of the
discharge process the need for ongoing support will be assessed on an individual basis. Referral either back to another
worker within hype or to other agencies will be made with the young person’s consent. Those who do not wish any further
support will at this point be discharged from the service.
All enquiries are welcome and should be made to:
Jayne Reed
Senior Community Mental Health Nurse
Hype
Tel: 0131 466 4607
Fax: 0131 466 4604
Community Detox Service
Referral Form
Date _________________
Referrer __________________
Name _________________
Address __________________
DOB _________________
GP ______________________
Drugs Used: Include Alcohol _____________________________________
Current Pattern of Use ___________________________________________
Drug Use History
Age Drug Amount Frequency Route Still Using
History of Mental Health
Age Problem Diagnosis Treatment Where Outcome Ongoing?
History of Medical Problems
Age Problem Diagnosis Treatment where Outcome Ongoing?
Social Situation/Environment
Current accommodation ______________________________
Accommodation problems ____________________________
Proximity to drug using circle _________________________
Current education/work status _________________________
Non drug using supportive/significant others
Name Relationship Length known Addictions? Support detox?
History of previous detoxes
Age Where Method Outcome Days drug free Relapse trigger
Motivating factors in previous detoxes
1
2
3
Motivating factors for this detox
1
2
3
Any other relevant information
Community Detox Service
Self-Assessment (please complete and bring to appointment)
Name__________________________________
How long have you been drug dependent? __________________________________
Have you ever detoxed before?
Yes/No (if no, go to page 3
How many detox attempts?_____________________________________________
When were these? (give month and year) __________________________________
Why did you choose to detox on these occasions? ___________________________
Where did you detox? _________________________________________________
Did you take any medication to help with detoxing? _________________________
Please state what:_____________________________________________________
How long did your detox (es) last? ________________________________________
Did you become opiate free? _____________________________________________
What is the longest you have been free of drugs?_____________________________
Who or what were supporting you through detox/abstinence?___________________
What have you learned about your addiction from your previous detox/ abstinence experiences? _________________________
Relapse
What led to your relapse(s)? Please circle all that apply.
Cravings
Depression Feeling stressed
Life pressures
Boredom
Lack of support
Anxiety
Family relationships
Feeling isolated
Prison
Couldn’t tolerate withdrawals
Being offered drugs
Realise didn’t want to stop
Didn’t know how to cope drug free
Other (please state)
Previous withdrawal experience
What withdrawal symptoms have you had before? ____________________
Was there any symptom you found too difficult to cope with? ___________
This detox
Why do you want to consider opiate detox now? _____________________
Are you taking any other drugs (including cannabis or alcohol)? Yes/No
If yes, what and how much do you take every day? ___________________
Are they prescribed? Yes/No. If yes, who prescribes? ______________
Are there any other drugs including cannabis and alcohol that you could not do without? Yes/No.
If yes, what? _____________________________
Will you continue to take other drugs during your detox? Yes/No
If yes, what? _______________________________________________
Do you want to be opiate free by a particular date? Yes/No. If yes, when and why?
Social Circumstances
Do you have children? Yes/No. If yes,
Name Age Gender Main carer
Do you have anyone living with you who depend on you to look after him or her? Yes/No. If yes, state
who and your relationship ________ __________________________________________________
Community Detox Service
Substance Use Diary
Name ______________ Week Beginning _______________________
Day What & How much
did you take
Where, when &
who with
Why did you use?
Physical
Emotional
Prescribing Service
Vital Sign & Opiate Withdrawals Monitor
Name ___________________________________
Date
Time
Signs
Insomnia
Sweating
Hot/Cold
Yawning
Diarrhoea
Rhinorrhoea
Sedation
Elation
Vomiting
Anorexia
Pilo-erection
Drug seeking
Restless
Agitation
Lacrimation
Observations
Blood Pressure MmHg
Pulse BPM
Pupil Size
Assessed by __________________________________________________________
Scores 0 – absent 1 – not sure 2 – mild 3 –moderate 4 - serve
Community Detox Service
Decisional Balance
Name ____________________________
What was/is good about current
drug use?
What was/is bad about
Current drug use?
What would be good about not
Using opiates?
What would you miss
About opiates?
Community Detox Service
Home Environment Assessment
Name: ____________________________
Availability of supporter
Always available 0
Often available 1
Sometimes available 2
Never available 3
Attitude of supporter
Very supportive 0
Supportive 1
Slightly supportive 2
Not supportive 3
Commitment of supporter
Very committee d
Committed 1
Slightly committed 2
Not committed 3
Level of noise
0Tranquil 0
Reasonably quiet 1
Noisy 2
Very noisy 3
Space to be alone
Ample room 0
Some room 1
Little room2
None 3
Presence of young children/pets
Nochildren or pets 0
Sometimes present 1
Always present 2
Presence is disruptive3
General Atmosphere
Very organised 0
Organised 1
Slightly disorganised 2
Disorganised 3
Presence of other substance users
Never present0
Sometimes present 1
Often present 2
Always present 3
Areas for Care Planning
Score______________
Prescribing Service
Treatment Aims
Name ________________________
Treatment Aim
Review Date
Young Person
Nurse
Date
Date
Community Detox Service
Suitability Assessment
Young person’s name_________________________
Date of birth __________________
Self Assessment completed and returned?
Yes/No
Decisional Balance completed and returned?
Yes/No
Substance Use Diary completed and returned?
Yes/No
Does the young person wish to consider lofexadine?
Yes/No
Baseline pulse: _________bpm
BP.: __________mmHg
Date and results of last urine screen:_____________________________
Health
Is there any physical/mental health history?
Physical:
Mental:
Medical Responsibility
Who is prescribing for detox?
Date prescription written
Date GP informed
Community Detox Service
Contract for Community Detox
Name_________________
For opiate Community Detoxification to take place safely, there are certain
conditions, which we expect you to follow.
1. You agree that the responsibility for any medication prescribed is yours.
2. You agree not to take opiate drugs (except those, which you are legitimately
prescribed,) throughout the detoxification process.
3. You agree to be randomly tested for drugs.
4.You agree not to be physically or verbally abusive to staff.
5. You agree to attend all arranged appointments.
Failure to comply with any of the above may lead to your community detox
being stopped.
Please sign here to show that you fully understand and are in agreement with this
consent form.
Young Person_________________________ Date_________
Nurse______________________________ Date_________
Community Detox Service
Date________
Dear Dr_________
Re opiate detox for name
dob
address
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I am writing to let you know that ____________ has completed their detox from
opiates. I will continue to see them for ten weeks relapse prevention. I will write
and inform you of their progress following this piece of work.
As you have previously agreed to prescribe Naltrexone for _____________, please
arrange for a prescription of Nalorex, __mg daily to be available for collection
from your surgery on ________.
Yours Sincerely
Jayne Reed
Senior Community Mental Health Nurse
Certificate of Achievement
is hereby granted to:
…………………..
to certify that you have tested negative for opiates
Well Done!
Granted: (date)
Jayne Reed, Senior Community Mental Health Nurse
Prescribing review
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Why were you referred to hype?
Why did you need a prescription?
What are you prescribed?
How has your prescription helped you?
Are there any negative effects of receiving a
prescription?
• How would your life be different if you hadn’t
received a prescription?
• Is there anything that could have been done
differently?
Why were you referred to hype?
• “Because I was using opiates (smack)”
• “I had a bad heroin problem at a very young age”
• “I just wanted to come off and the doctor told me to come
to hype for help because hype specialises in this help”
• “I referred myself cause I wanted to get off heroin as it was
no life”
• “Spoke to my social worker about being on kit. Told him I
had been before for hash. He organised a meeting”
• “My mum’s support worker thought it might be good for
me. That was the first time I really spoke about my drug
problem”
Why did you need a prescription?
• “Because I had a habit. I wanted to come off. It’s hard
though, it’s really addictive”
• “Cause I wasn’t strong enough to do it on my own. I tried
to go cold turkey with my mum and dad but it didn’t work”
• “To help me come off street drugs. To stabilise me. That’s
me probably contradicting myself as I’ve used on top”
• “I wanted 2 come off heroin without withdrawing so I was
prescribed methadone and it made me feel normal or ok”
• At first I didn’t think I needed one. I changed my mind –
It feels cleaner than heroin & it feels like I’m more
supported, friends, family, even the chemist”
What are you prescribed?
• “30mls methadone”
• “85mg methadone”
• “32mls methadone (currently on a 3ml per week
reduction from 70mls)”
• “At the moment in time I’m prescribed 8 yellow
valleys (diazepam) each day and 30mls of
methadone”
• “40mls methadone”
• “30mls methadone”
• “80 mls methadone”
How has your prescription helped you?
(both physically and in other areas of your life)
• “Stopped me from withdrawing. I’d probably be at rock bottom, probably
dead”
• “It has kept me off the heroin for the last 2 years”
• “It has helped me with my baby boy. Being clean and drug free for him. So
all my attention is focussed on him. You counsel us as well, it’s not just the
prescription”
• “Physically I can get up out of my bed without rattling and I can do what I
want to do all day without running around trying to get smack”
• “My prescription helped with family because I wasn’t taking heroin, just my
medication”
• Don’t feel weighed down worrying about money, heroin or health. Able to
cope better”
Are there any negative effects of
receiving a prescription?
• “You do not want to have to take methadone every
morning but in my case I have to or I will be very ill”
• “Nope”
• “Being supervised at the chemist, I bumped into my old
best friend and it was embarrassing”
• “My teeth are rotting. I feel funny going into the chemist
everyday as they all know – it’s a wee bit embarrassing”
• “I guess sometimes you wish you didn't have to go to the
chemist every day, feels quite a tie but when I think about
before I prefer this to before”
How would your life be different if you
hadn’t received a prescription?
• “Looking really unhealthy and skinny, looking 4 times as worse as before I
went into secure”
• “I would probably be in the jail (stealing to get money for heroin)”
• “Probably wouldn’t have my baby girl – cause you helped me when I was
pregnant. I probably would’ve had to have an abortion”
• “I moved house recently – only did 3 trips. Moving in was 20 trips but sold
all my stuff”
• “I probably wouldn’t be here to answer that if it wasn’t for the staff”
• “I probably wouldn’t have fallen pregnant and I probably would’ve had him
taken off me as well” (on C P register)
What do you think about the assessment
process for prescribing?
• “I liked doing the drug diaries”
• Thought it was quite long. Asked me questions that I
hadn’t thought of before. Gave me a wake up call”
• “Alright. Planning each day was over the top” (during
detox) *dad disagreed!
• “It was a nightmare – to be honest, just because you expect
it straight away”
• “The hardest bit was coming in withdrawing to see the
doctor”
• It was stressful but I was feeling happy at the same time
because I was getting a prescription”
• “I think they are doing the right things, always have”
Is there anything that could have
been done differently?
• No and I’m glad it has been done this way because
I still have my life at the moment thanks to the
doctor and nurse but we are still working together
to sort this very weird problem out as quickly as
possible”
• “I don’t like my chemist at all but nothing else”
• “You do everything okay”
• No. Not that I can think of”
Is there anything that could have
been done differently?
• “I always wanted dihydrocodeine and diazepam as I
thought they would be easier to come off. I think I
was a bit young for methadone. I now think I
should’ve tried Subutex. I think folk should try that
first”
• “When I was on the detox, I had to come up every day
and get checked every day. I would rather have stayed
in my bed”
• “Not really, everything here was fine. Maybe I could
have done things a little differently but I didn’t. I
could’ve stuck to my prescription and not taken smack
- don’t think I was ready it wasn’t the right time”
References
• Crome IB, Christian J & Green C (2000) A unique designated
community service for adolescents: policy, prevention and
education implications. Drugs Education, Prevention and Policy.
7, 87-108.
• Crome IB (2004) Treatment. In Young People and Substance
Misuse. (eds Crome IB, Ghodse H, Gilvarry et al). London:
Gaskell
• Department of Health (1999) Guidelines on Clinical
Management: Drug Misuse and Dependence. Norwich:The
Stationery Office.
• Health Advisory Service (2001) The Substance of Young Needs.
London: Drugs Prevention Advisory Service, Home Office.
• Stewart DG & Brown S (1995) Withdrawal and dependency
symptoms among adolescent alcohol and drug abusers. Addiction.
90, 627-635.