Transcript Implementation of a protocol for prescribing and

Tallaght
October 2010
Where Are We Now ?
Margaret Bourke
GP Coordinator
Partnership

This is the story of what I see as a very
successful partnership to provide treatment to a
very disadvantaged group in society. Also to
bring dignity and caring to the workplace and to
provide it to this cohort. Those of you who were
here in the early days will remember when
treatment was provided in less than ideal
venues and we were not provided with a red
carpet welcome and serious attempts were
made to stop us providing treatment.
Addiction
Is a chronic recidivist illness
 The object should be a functioning lifestyle
on treatment, with abstinence for those
who can achieve it.
 It is a disease of neuro chemical
pathways. Specific opiate receptors have
been identified.

Changing Attitudes
“Addictive disorders should be
considered in the category with other
disorders that require long-term or life
long treatment. The treatment of
addiction is about as successful as
treatment of disorders such as
hypertension, diabetes and asthma. It
is clearly cost effective…….and as
with treatment of these other chronic
conditions there is no cure”
Background



The epidemic of heroin in the mid 1980s and
the explosion in the 1990s which continues
into the 21st century has led to enormous
problems with healthcare
Addiction is an illness which needs treatment
There is an increasing need to respond with a
statutory duty to provide a multidisciplinary
service
Advent of HIV




Led to a demand for stabilization and
maintenance treatment programs with
methadone.
In response, the then Eastern Health Board set
up services.(1992)
What commenced as a HIV prevention
programme rapidly became a response to the
problem of heroin use.
Increasing evidence of Hepatitis C in injecting
drug users fueled the need for treatment.
Needle Exchange
First Exchange 1988
 Statutory Services 10
 Back Packing
 Out Reach
 N G O large city centre N E funded by
HSE and Private Donations
 Tallaght JADD Oct.2002, St. Aengus 203

Treatment
Prior to 1992 most treatment was
abstinence orientated
 Prior to the Protocol most treatment was
based in Central Services
 Community a Number of Untrained
Practitioners Prescribing for a Large
Number of Patients

Background
Significant Heroin Problem
 Problematic use concentrated in Dublin
 Advent of HIV Epidemic led to a change in
Policy
 Harm Reduction Philosophy Embraced
 Most Treatment Methadone Maintenance

Central Service
Addiction Treatment Centers
 Satellite Clinics
 Drug Treatment Centre
 Prisons
 Cuan Dara

Central
Treatment Services
August 1992 first Addiction Treatment
centers opened. There are now 23
centers in the Dublin area.
 March 1995 first Satellite clinic opened in
Tallaght. There are now 43 such clinics in
the Dublin area.
 The Drug Treatment Centre (Trinity Court)

Addiction Treatment Centre

More Challenging Patient Cohort
 Polydrug Use - Alcohol,
Benzodiazepine,Cocaine
 MultidiscipliniaryTreatment Team
 On Site Dispensing
Developments
Treatment Centers



Have increased in number from the two opened
in 1992 to twelve with the agreement of local
communities.
Staffed by G.P.S specialising in substance
misuse working as part of a multidisciplinary
team.
All methadone is dispensed on site.
Satellite Clinics

Partnership between Health Service and
Communities
 Treatment Provided by Statutory Services
 Members of a Multidisciplinary Team
attend on a sessional basis.
 Methadone Dispensed in Community
Pharmacies
 Prescribers: General Practitioners
Specialized in Substance Misuse
Drug Treatment Center Board
(DTCB)


Staffed by Consultant Psychiatrists and NCHDs
More difficult patients
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Serious psychiatric illness
Serious behavioral issues
Amacus service
Temporary Transfer
Patients where no service available in area
Homelessness
Treatment Services
Other HSE areas provide treatment
 Not adequate, patient transfer difficult
 Prisons, treatment provided to

 Those
already in treatment
 HIV positive
 If agreed with HSE Addiction Services
Detox/ Abstinent Services
Medical Supervision
Cuan Dara: six week programme also
stabilisation programme especially for
those pregnant
 Keltoi: Post detox three months
 Link with other agencies

 Lantern
 Cuan
Mhuire
 Coolmine
 Simon Community (Alcohol Detox)
Treatment Provision

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

A protocol for the prescribing of Methadone in
the community was set up in October 1998.
Treatment continues to be mainly centred in
Dublin but has expanded to different areas of
the country
Prior to the protocol most treatment services
were provided in Central Services.
There were a number of untrained G.P.s
prescribing for a large number of patients
Background

March 1993


March 1995


Department of Health and Children (DoHC)
published a report on the establishment of a
protocol for the prescribing of methadone
A pilot project for the implementation of the
protocol was commenced
October 1998

Protocol which had been signed into law in July
was implemented
Protocol Objectives
To normalize patient attendance in
community based services
 To encourage G.P.s and Community
Pharmacists to become involved in
prescribing and dispensing methadone
 To provide ongoing training and education
for G.P.s and Pharmacists

Protocol Structure
Methadone is a controlled drug
 Oral Methadone D.T.F 1mg/ml is the only
available preparation
 Specific Protocol Prescriptions issued
 Treatment Cards provided for each client
and held at the designated pharmacy

Treatment Card


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

Name and Address
of Patient
Designated PH
Number
Photograph
Name, Address and
Tel of G.P and
Pharmacist
Signature of Patient
Structure

National Central Treatment List
Established
Confidential
 Access only by doctors and pharmacists

Treatment is Free to all patients
 Special Payments to G.P.s and
Pharmacists

Structure

Level I G.P.s


Providing treatment for up to 15 stabilised patients
Level II G.P.s
Providing and/or initiating treatment for up to 35
less-stable patients


Maximum of 50 patients per practice


G.P. or Pharmacy
Appointment of GP Coordinator and Liaison
Pharmacist
GP Coordinator and
Liaison Pharmacist



Encourage Community G.P.s and
Pharmacists to prescribe and dispense
methadone
Initial and Ongoing Training and Education
Provide ongoing support and back up to
community G.P.s
Overview of Protocol

Specialised Training for GPs and
Pharmacists

Guidelines issued by Irish College of General
Practitioners

Evidence based consistent with Eurometh
Guidelines
On-Going Developments


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On-Going Training for G.P.s and pharmacists
Continuous Liaison and back-up services
provided by GP Coordinator and Liaison
Pharmacist
Auditing of GP patient profile
Initiation of patients by G.P.s (Level II)
Transfer of stabilised patients to Level I G.P.s
Aim of Methadone Treatment

Reduce illegal heroin use

Improve Social stability

Reduce morbidity and death

Prevent transmission of blood borne viruses

Coincidently it reduces crime
Treatment Options - Medical
Methadone Programmes
 Detoxification associated with high relapse rates
 Reduction Programme stabilisation and dose
reduction over a period of six months or longer.
 Maintenance Programmes
The most evaluated treatment and probably the
most successful
 Counselling
Other Treatment Options
Buprenorphine
Substitution treatment available for a
feasibility study
 Lofexidine
Used in Detoxification programmes
 Naltrexone
Used Post detoxification

A blockade dose is the individual
dose, which prevents :
Opioid abstinence syndrome including
subjective symptoms of withdrawal as well
as objective findings.
 Reduction or elimination of drug hunger or
craving.
 The blockade of the euphoric effect of any
illicitly self administered illegal drugs.

Blockade Dose

Blockade Dose is usually 80mg + 20mg.

Most patients blockade at 80mg.

Patients with a high tolerance 90mg –
120mg.

About 7% of patients require a higher
dose.
Side Effects of methadone
Constipation
 Antitussive effect
 Myosis
 Increased bladder
tone
 Overdose

Blushing
 Itching
 Sweating
 Flushing.
 Prolonged QTc
 Respiratory
depression

Buprenorphine
Partial mu agonist
 Less respiratory depression
 Quicker safer induction
 Cost
 Street diversion ( injected )

PROBLEMS IN STABLE
PATIENTS
Misuse of legally prescribed drugs
 Use of illegal drugs
 Alcohol
 Increase in psychiatric illness
 Pregnancy
 Hepatitis C
 HIV Infection

Other Illegal Drugs of Misuse
Cocaine
 Ecstasy
 Cannabis
 Head Shop Substances
 Methamphetamine

Cocaine
Cocaine is a powerful and addictive
central nervous system stimulant
 Use leads to euphoric state known as a
“high”
 Neurobiological studies suggest it taps into
the brain reward system
 Increased use since 1998 as a ‘street
drug’

Peak Concentrations
Nasal inhalation - 5 to 20 minutes
 Smoking: free based or as “crack” –
seconds
 Intravenous – seconds

Ecstasy
Use began in the late 1980s with the
advent of the Rave culture and emerged
as a problem in the 1990s.
 Oral use, effects occur within 30 minutes
can last for 4 hours.
 Mood Change – Euphoric – Confident
 “Crash”, severe lassitude and fatigue

Cannabis
Adolescent use can induce serious
psychiatric illness
 Affects concentration

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Drop out
Do poorly in education
Gateway
Head Shops
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Still available, Mephadrone, BZP-derivatives,
‘Spice’, Skunk
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Under the counter
Street
Internet
Hallucinogenic: Mescaline and LSA compounds
Kratom opioid agonist
Salvia Magic Mint
Sida Cordifolia ephedrine
Caffeine with Guarana 100 times more potent
injected
Methamphetamine
U S Canada (Vancouver)
 Eastern Europe Russia
 Injecting culture
 Meth Labs ( Mexico U S)
 Pseudo ephedrine containing compound
 Cough bottles (antihistamine)

Misuse of prescription medications
Benzodiazepines
High rate of misuse in methadone
maintained patient
Misuse of Drugs Act 1993 Rohypnol,
Temazepam.
Report of Benzodiazapine Committee 2002
 Antidepressants
Triptyzol, Prothiaden, Zispin
 Antipsychotic medication olanzepine
 Hypnotics Zimovane, Dalmane

Misuse of OTCs

Codeine

New Pharmaceutical Society Guidance Aug
2010
Antihistamine
 Cough Bottles

ALCOHOL
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Most common ‘drug’ of misuse in Ireland
Gateway
Cross addiction is common
May revert to alcohol when opiate stable
Safe prescribing is necessary
Acamprosate (Campral EC), Disulfiram
(Antabuse)
Detox Inpatient, Chlordiazepoxide (Librium)
HEALTH
Poor health is common in this group of
patients.
 Lifestyle
 Poverty
 Immunosuppressive effect of opiates and
cocaine.
Dual Diagnosis

Many with substance misuse have co-morbid
psychiatric problems.

Increased level of symptoms in polydrug
users.

Higher risk of suicides in this group of
patients

Higher incidence of depression, some studies
show 50% of opioid & cocaine users to report
life time depression
Psychiatric Illness
 Paranoia
and Psychosis
 Can be induced by ecstasy,
cocaine, amphetamines
 Personality Disorders
Pregnancy : Management

Prioritized access to treatment
programmes

Stabilizing heroin addiction


Central Services
Maintaining stability

Prevents cycling effects of unstable drug
use
HIV

10 years after infection, 50% of patients have
had a HIV related illness

10 % of patients on M. M. in Dublin are HIV+ve

HIV related illness
-
Treatment
Long term chronic illness
 Triple Therapy
 Varying combinations of antiretrovirals
appropriate to the individual

Hepatitis C

70 – 80% of drug users (Ireland) are Hepatitis C positive
-75% asymptomatic
-PCR positive – genotypes 1and3

Cirrhosis
- Alcohol
End Stage Liver Disease
Treatment – Pegylated Interferon/Ribavirin
New treatments to come on stream in 2011


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Hepatitis B
All Health care professionals must have
hepatitis B vaccinations
 Hepatitis B vaccination protects you
-bite
-needle stick injury
-blood splash

Needle stick injury

Risk
-HIV 0.3%
-Hepatitis B 40 – 60% (if patient E antigen +ve)
-Geographical
-Hepatitis C 5-8%
-risk dependant on degree of penetration
-amount of blood inoculated

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Universal Precautions
Treatment / PEP
Overdose
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Higher risk 2 weeks following prison release
Post detoxification
Treatment induction
Cocktail
-benzodiazepine
-alcohol
-heroin/methadone
Cocaine
Ecstasy
Overdose

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Greater risk in older persons, increased risk of
death if injecting into the 30s
69% of illicit drug users have experienced a non
fatal overdose
Homelessness
Poly drug Use
Depression
Suicide
Overdose

Emergency assistance is sought in only 25
–50% of cases
-peer based management
-CPR/ Naloxone (minijet) / Information
leaflets
STUDY IN S.W.A.H.B.
(Norway Europad)




Retrospective analysis of data collected prior to
and after the implementation of the protocol in
specific postal districts of the SWAHB.
The post implementation figures are between
Oct 98 and May 02
Impact of the protocol on a deprived suburban
area with a population of 90,000 is also
described.
Numbers of patients now treated in General
Practice are shown.
RESULTS
G.P. participation increased by 185%
 The number of Level One G.P.S increased by
157%
 The number of Level Two G.P.S increased by
400%
 There was an increase by 318% of patients
treated at level one.
 Increase by 255% of patients at level two
There was a 95% increase in pharmacies
dispensing to patients prescribed in general
practice

Results from Suburban Area
9%
1998
91%
51%
2002
Central
Services
49%
Primary
Care
Participating G.P.s and Pharmacies
12
10
8
6
1998
2002
4
2
0
No. of
Pharmacies
Level I
Level II GP
Conclusions

1998 - 2002
 Significant Increase in number of Patients
in Treatment
 Facilitated by Partnerships with
Communities in Satellite Clinics
 Facilitated by implementation of Protocol
enabling General Practitioners and
Pharmacies to Prescribe and Dispense
Tallaght

Satellite Suburban City Population 100,00
 Explosive Building Expansion in the last
30 years
 Poor Amenities
 Crime
 Heroin
 Disempowered Communities
Attempts to Implement Services

Communities Disempowered by Addiction
 Community Fears around Treatment of
Drug Users attracting undesirable antisocial behaviour
 “Not in my Backyard” Syndrome (NIMBY)
 Led to Opposition to Provision of
Treatment
 Expressed through Anger, Marches
Difficulties
Communities were threatened by
Treatment Services, perceived as
Medicalization of “Heroin Problem”
 Issues of Patient Confidentiality
 Boundary Issues

Relationship Building

Consultation and Dialogue through
Meetings
 Conflict Prevention
 Building Trust
 Strategy for Empowerment of
Communities
 Conflict Resolution
National Drug Task Force
Set up in 1996 to
 Help Communities combat the Epidemic of
Heroin Use
 Provide Funding for Local Community Projects
 Representation: Health Service Executive
(HSE), Departments of Justice, Education,
Enterprise and Employment
 Local Community and Voluntary Organisations

1996 June, first patient transferred to
a Level 1 GP during the Protocol
Pilot.
 1996 November, first Satellite Clinic
opened.
 1997 March 1997 two further satellite
clinics opened.
 1998 October, an Addiction
Treatment Centre opened as an
evening service only.
 1998 October, two farther satellites
came under the umbrella of the HSE.

2001 August a Mobile Bus service
commenced as a Central Addiction
Treatment Service.
 2005 March a large Addiction Treatment
Clinic.
 With the opening of this service the
evening clinic and mobile clinic were
incorporated into the Addiction
Treatment Centre.
Outcome

Community partnerships with Health
Services
 Catchment Service Provision
 Statutory Services Enabled to Provide
Treatment
Increase in Number of Level I and Level II
G.P.s
1998
2002
2005
16
14
Level I
4
12
15
12
10
1998
Level II
0
3
4
8
2002
2005
6
4
2
0
Level I
Level II
Total number of patients in Treatment
800
700
1998
2002
2005
600
500
400
204
593
745
Total No in
Treatment
300
200
100
0
2002
Total Number of Patients in Treatment in
Community Practice
Patients
350
Year
1998 2002 2005
300
250
200
Patients
150
100
Patients
18
292
304
50
0
1998
2002
2005
Total Number of Community
Pharmacies Dispensing
Year
1998 2002 2005
Pharmacy
16
14
12
10
8
Pharmacy
6
4
Pharmacy
3
12
15
2
0
1998
2002
2005
Total Number of Patients in Central
Services
Central Services
Year
1998 2002 2005
450
400
350
300
Central
Services 186 286 422
250
Central Services
200
150
100
50
0
Year
1998
2002

2002 - 2005
 Opening of Addiction Centre
 Further Expansion of Community General
Practice and Pharmacy Service
 Led to enormous reduction in Waiting
Lists and Increased Access to Treatment
 Use of Treatment Services to facilitate
Employment and further education
2005 to Date
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Waiting time for treatment from Initial
Assessment 2 to 3 weeks ---- administrative time
Change in age profile
Most patients re-applying for treatment (patients
know to us)
Referrals from Hospital and Prison
Patients in Secondary / Tertiary Education
accommodated regardless of stability unless
difficult polydrug user not suitable for pharmacy
Easy access to Hepatitis C treatment
Total Numbers in Treatment
End of July 2010
Total number in treatment 9581
 Outside Dublin in clinics 321
 Prison
730
 Dublin DML and DNE Clinics 4641
 Drug Treatment Board 525
 Community Practice DML and DNE 3100
 Community Practice (outside Dublin) 565
 Number in Pharmacies Dublin 4999

Numbers in Treatment in Tallaght
End of July 2010
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Number in Addiction Treatment Center 249
Number in Satellite Clinics 250
Number in Community Practice 314
Number dispensed in Pharmacies 564
Level I G.P.s 16, Level II G. P.s 4
Number of community pharmacies in Tallaght 15
Number of fringe pharmacies 4
Percentages in Community/Central
Services
61
39
Numbers in primary
Care
Numbers in Central
services
Applications for treatment
Vast majority are people who have
previously been in treatment
 A number of treatment naive persons over
40 have applied in past 12 months
 Few applications for treatment persons
under 25
 Age profile older

Homelessness
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Greater prevalence of substance use among the
homeless population
Predominant public health issue in this cohort
Higher incident of psychiatric co-morbidity
Particular difficulties in treatment provision
-residential instability
-poor economic and employment status
-social disaffiliation
Services
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Structure on provision of service by Multi
Disciplinary Health Link Team in Dublin City
South
Once clients linked remain even if transferred to
another area
Advocacy and contact with voluntary services
e.g. Simon Community and statutory agencies
Transitory homeless residency
Transfer to city
Caring

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Addiction is an illness which needs to be
treated
Only by working with drug users and trying to
understand the risks they run can we begin to
be accepted by them in a caring role and so
be in a position to engage with them.
We need to help patients who wish to deal
with their drug habit, we do not refuse to treat
alcoholics or nicotine dependant patients so
why judge opiate dependant patients?
Patience and flexibility are a necessary
component of this work. A non
confrontational, non judgmental, caring
approach is very important.