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THE MEDICAL MANAGEMENT OF DRUG DEPENDENCE

THE MEDICAL MANAGEMENT OF DRUG DEPENDENCE. Dr Sally Read CRI The Gate, Harrogate. Why primary care for drug users?. Chronic disease (cf diabetes, hypertension) Holistic care in a social context Normalising, less stigmatising Drug use affects whole family

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THE MEDICAL MANAGEMENT OF DRUG DEPENDENCE

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  1. THE MEDICAL MANAGEMENT OF DRUG DEPENDENCE Dr Sally Read CRI The Gate, Harrogate

  2. Why primary care for drug users? • Chronic disease (cf diabetes, hypertension) • Holistic care in a social context • Normalising, less stigmatising • Drug use affects whole family • GP strengths in health promotion etc

  3. Why are some GPs reluctant? • Lack of training and support • Time commitment – more consultations per patient • Fear of demanding / offensive behaviour • Fear of violence • Prejudice

  4. What the GMC says: “ It is…. Unethical for a doctor to withhold treatment from a patient on the basis of a moral judgment that the patient’s activities or lifestyle might have contributed to the condition for which treatment was being sought. Unethical behaviour of this kind may raise the question of serious professional misconduct”

  5. Hierarchy of Treatment goals • Harm reduction • Health promotion • Stabilisation • +/- Maintenance • Reduction • Detoxification • Abstinence • After Care or Relapse prevention

  6. 2011 – The recovery journey • What is recovery? Controversy over “medically assisted recovery” versus abstinence…. AND what medically assisted recovery means. Try a web search if you are interested!

  7. CRI Medically Assisted Recovery • Titration • Stabilisation and Reduction OR Maintenance (long term stabilisation) • Detoxification AND after care

  8. Harm reduction • Avoid injecting / safe injecting • Hepatitis B immunisation • Screening for bloodborne infections • Reduction of overdose risk • Safer sex • Methadone in the home

  9. Drug worker assessment – history of use, personal, social and family history, assessing motivation, motivational enhancement, goal setting. Multi-agency working Substitute prescribing: methadone, buprenorphine Stabilisation and reduction

  10. Reduces injecting and illicit drug use Reduces transmission of bloodborne infection Improves health Reduces risk of overdose and death Reduces crime Other social improvements Benefits of methadone

  11. Effective methadone programmes • Flexible doses, higher doses • Adequate duration of treatment • Psychosocial support • Goal of maintenance rather than abstinence • Positive staff attitudes • Avoidance of punitive approach

  12. Avoiding dangers of methadone: • For patient • For members of the household, especially children • For the public……… DAILY DISPENSING, SUPERVISED CONSUMPTION

  13. BUPRENORPHINE • Increasing use • Sublingual • Partial agonist / antagonist • Probably more hepatotoxic • Less suitable for very heavy users • Much reduced risk of overdose • Daily dispensing – easier to divert?

  14. Suboxone • Buprenorphine and naloxone – if crushed and injected, naloxone will block the agonist activity of buprenorphine, but is inactive sublingually.

  15. Safe prescribing – what are we trying to avoid? Problems for the patient Problems for the Service Problems for society

  16. PROBLEMS FOR THE PATIENT • Over prescribing, leading to: • Increasing dependence • Overdose • Death (heroin users have 12x mortality rate of general population, injecting users 20x mortality rate of non injectors)

  17. PROBLEMS FOR THE SERVICE • Disruption for other patients • Disruption for staff • Disruption for doctors • Directly • Indirectly through added stresses

  18. PROBLEMS FOR SOCIETY • Street diversion and crime • Risks to dependent children • Safety caps for take-home doses

  19. Appointments • ? Named doctor for each drug user • Patients without an appointment • Arriving late? How late? • Asking for house calls to discuss script?

  20. Prescriptions • Replacing lost / stolen prescriptions • Replacing lost/ stolen medication • Giving prescription early • Giving prescription for longer periods to cover holidays, crises etc

  21. What would you do in the event of? Patient shouting Patient threatening Patient being violent When should the receptionist call for help? When should the police be called? How will GPs respond? Critical event analysis BEHAVIOUR

  22. ‘Drug-users have often lacked parenting, or at least appropriate parenting, and may be stuck in adolescent behaviour. In order to mature they need care and concern on the one hand, and firm and consistent boundaries on the other. In order to provide such boundaries, practices benefit from an agreed written policy about working with drug-users’ (Judy Bury) • Policy should be: • “flexibly rigid” • Owned by all workers and reviewed regularly • Patients aware • Sanctions applied consistently

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