Shared Care – I n Practice

1. Shared Care – In Practice Dr Sue Pritchard Shipston Medical Centre

2. Substance misuse treatment in primary care- why bother? • Chronic relapsing condition – similar to others treated in primary care • Mortality 14 x higher for age matched controls • Morbidity: 90% cases of hep C in UK are associated with IVD use

3. Why bother…. • Effective evidence based treatment with good outcomes • Needs holistic individualised approach – cornerstone of GP care • Good for our communities

4. Effects of dependant drug use • Physical: BBV transmission, complications of injecting including VTE, abscesses, Endocarditis, Poor pregnancy outcomes, Overdose. • Social: Effects on families, criminality, imprisonment, social exclusion • Psychological: Fear of withdrawal, craving , guilt, stigma • Mental health: depression, psychosis, dual diagnosis

5. Evidence based treatments • Reduces mortality significantly • Reduced drug related morbidity • Reduces crime • Reduces risk taking behaviour and spread of BBV • Can be done safely without increasing methadone mortality

6. Guidelines • RCGP Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care – 2011 • Drug misuse and dependence - UK guidelines on clinical management • RCGP Certificate in the Management of Drug Misuse

7. What is Treatment? • NTA describes range of interventions which are intended to remedy an identified drug related problem or condition relating to a person’s physical, psychological and social well being • Structured drug treatment follows assessment and is delivered with a written mutually agreed care plan, which is regularly reviewed

8. Treatment and ‘Recovery’ • Political shift towards recovery approach which NTA frames ‘in terms of achieving an individual client’s goals for making positive changes in their lives’. • This is underpinned by more personalised approach to treatment and a balanced system including, even encouraging, abstinence orientated treatment

9. Recovery • A patient’s unique journey • Shared care patients -often stabilised, housed, employed, family • Need opportunity to discuss reduction • ‘ Treatment should end at the point of the patient’s journey which the patient and the prescriber judge to be clinically (not politically or morally) safe and appropriate’

10. Philosophy • More than just methadone • Therapeutic alliance • Motivational interviewing – Rollnick and Miller • Engagement – attitudinal approach throughout team • Holistic approach • Family support - ESH • Safeguarding Children • Safety of medicines • DVLA

11. In Practice • New patients seen by SCP/PD • Contact previous GP/CDT team • CDT full assessment with positive swabs and contract • Harm minimisation – Hep C /HIV/Hep B testing, accelerated Hep A /B vaccination schedule. • Overdose prevention advice • Needle exchange scheme at local chemist and needle bin at Ellen Badger Hospital

12. In practice… • Maintenance until stability achieved • Regular health check – aging population! COPD/Hep C/Alcoholic cardiomyopathy • Contraception and STIs • Cascade alerts re contaminated batches • Boundaries – not punitive but consistent • Negotiation re pick ups • Life without drugs – the role of ‘meaningful activity’

13. In practice • QOF and chronic disease - depression screening questions • Evidence that PHQ9 and GAD score can be used with patients within addiction services. • Improved flexible working with CMHT especially IAPT

14. Ongoing care • RCGP guidelines: • Treatment reviewed at every contact and needs to be re-examined more formally every 3-4 months to measure improvements in health and wellbeing and to monitor any use of alcohol or drugs and given support to make changes • Toxicology screen frequently at start of treatment and when stabilised two to four times a year.

15. High dose Methadone and risk of sudden cardiac death • Torsades de pointes – ventricular arrhythmia associated with prolonged QTc interval • All those on methadone 100mg or above • Those on methadone + additional factors • Lithium, SSRI, TCA, sotalol, venlafaxine, macrolides • Structural heart disease • Offer ECG – if normal, repeat every 12 months • If abnormal – discuss change in script, reduction in dose, consider cardiology referral

16. In practice • Therapeutic relationship requires trust and continuity • Continuity of CDT worker and GP • Positive attitude from Primary health care team • Good communication – plans in place, swab results available • Flexibility of CDT worker and GP • Engagement and signposting for other psychosocial issues • Consistency in approach by other GPs in the practice. Annual clinical meeting • Professional peer support