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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? • 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 • 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.Gowing L, Ali, R, White, J. Buprenorphine for the management of opioid withdrawal. Cochrane database of systematic reviews 2006. Issue 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 • completion of in-patient program • attendance at aftercare • not using IV • absence of family history of using
Daryle Deering et al. NAC ‘Barriers to Care- A Service Users Perspective’ 2008
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%) • Deering et al 2008
GP liaison for methadone prescribing • Criteria for GP prescribing • Process for transfer • Ongoing monitoring • Responsibility of care • What happens when the wheels fall off?
Criteria for GP prescribing • 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 • 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