Drug misuse and dependence: UK guidelines on clinical management

Transcription

1 Drug misuse and dependence: UK guidelines on clinical management Response by Cornwall Council Date 2014 Service responding: Drug and Alcohol Action Team (DAAT) Directorate: Education, Health and Social Care

2 Introduction Drug misuse and dependence: UK guidelines on clinical management was published in 2007 and have been one of the foundation for treating drug dependence in the UK. Much of the advice given in the 2007 guidelines, often called the orange guidelines or orange book, remains current. However, Public Health England (PHE) is consulting on whether sections could benefit from being updated following developments in the evidence base. An update would build upon the original version to reflect new evidence, issues and ways of working, as well as developments in the recovery orientation of drug treatment. An update would also seek to complement and supplement other key documents, including NICE guidance and Medications in recovery. PHE would like feedback from stakeholders about: whether the 2007 guidelines need updating, including: what recent evidence needs to be reflected in the update whether there are gaps in the current guidelines where additional advice is needed Question 1 agree disagree Do you agree with the review proposal: that Drug misuse and dependence: UK YES guidelines on clinical management should be reviewed and updated? Question 2: What recent evidence needs to be reflected in the update? General comments that relate to the whole document Comments Insert each new comment in a new row Foreword Page 7: Use of the word clinician to be updated to include specialist medics, NMPs, prescribing GPs, and the particular role of dispensing pharmacists & supervised consumption. The current guidance is far too specialist medical in character. Should also include clinicians in mental health and pain management, as these are underdeveloped dual diagnosis services across the country. Who are the Clinical Guidelines for? These should now include DAAT Joint Commissioners and Local Authority Directors of Public Health, as they are equally responsible to ensure providers comply with the guidance. See Francis report for Mid-Staffordshire NHS F Trust. Rural Communities: The guidelines should better recognise and reflect the particular challenges and minimum standards required in delivery across wide rural areas. Recovery Approach: We expect the guidelines to incorporate key recent guidance, in particular Medicines in Recovery (Strang et al) and Independent Expert Review of ORT in Scotland (Kidd et al 2013). This should reinforce principles of prescribing always within a wider recovery plan, and never outside a wider treatment system (no lone prescribers). Reinforce replacement prescribing or symptom management as one element that supports wider recovery planning within a wider professional collaboration of care delivery. NHS changes: Updated guidance must recognise the challenges brought about by the recent changes to NHS structures and governance to ensure effective local arrangements for safe use of CDs that used to be overseen by Medicines Date September

3 Management Teams within PCTs. Local Authority commissioners/daats and service providers no longer have free access to that important resource. Ensure standards outlined between CCGs and NHSE (e.g. The Controlled Drugs (Supervision of Management & Use) Regulations 2013 NHSE) are incorporated, as these regulations seem mainly to apply only to CCGs at present leaving LAs & DAATs outside any Memoranda of Agreement locally. Alcohol & other drugs: Include clinical responses to new psychoactive substances, benzodiazepines, and stimulants in greater detail. The current guidance is too opioid focused to address the diversity of current patterns of street drug use, particularly among younger people. Consider whether to include alcohol treatment interventions within this guidance, given that problematic drug use rarely occurs alone. Chapter 1: introduction Ensure DAAT joint commissioners (now within LA) embed an effective governance framework to manage the safe supply of prescribed CDs within their drug treatment & recovery system It is not only doctors that have specialist clinical competences. See comment above It is now the responsibility of LA commissioners to ensure good clinical governance. This is a major change of responsibility since NHS changes Chapter 2: clinical governance 2.1 Too much emphasis on the clinicians and not enough on the crucial roles of recovery co-ordinators and service users themselves in the delivery of care. Too much use of the word treatment and collaboration between clinicians rather than the wider team of mixed professionals. Too medical in language & approach. Needs much stronger emphasis on the wider multidisciplinary team approach to treatment & care. This section should incorporate and reflect Clinical governance in drug treatment - A good practice guide for providers and commissioners (NTA 2009). 2.1 Update to reflect the new responsibility of LA commissioners to ensure good clinical governance across the integrated system of commissioned services locally (see Francis Report ). This is a major change of responsibility since NHS changes 2013 & the removal of PCTs. That responsibility should be emphasised here. Each LA must have in place an effective & inclusive governance framework to support commissioned clinical interventions, particularly the prescribing of controlled drugs. Most charitable or private market providers are no longer linked in any way to NHS provision, nor are their systems of governance. 2.4 NMP section needs updating to include the Independent Prescribing of CDs status of NMPs that was not in place at the time of original guidance Emphasise the importance of clear communication between Date September

4 clinicians involved in any care plan especially where there may be both specialist prescriber and GP or psychiatrist prescribing of psycho-active drugs (dual diagnoses), e.g. opioid prescription from specialist prescriber and benzodiazepines/anti-depressants/pain relief prescribed by GP/psychiatrist. Routine & reliable communications in both directions should be the norm. Model pathways for concomitant pain management and drug dependence treatment would be of great use. Chapter 3: essential elements of treatment provision 3.1 Drug and alcohol testing can be a useful tool It is very important to ensure this section is kept in. Harm reduction and the minimisation of risk is still of paramount importance in D & A treatment & care, to maintain the balance with the helpful stronger emphasis on abstinence and full recovery more recently See Models of Care NTA 2003/2006 for more up to date best practice and guidance.. Establish minimum standards for frequency of clinical & recovery plan reviews, clinical supervision, & communications across treatment team Emphasise the need for effective communications and record keeping. 3.4 Promote better alcohol testing, particularly when prescribing opioids The concept of aftercare is a bit archaic and does not recognise that recovery support is ongoing - beyond structured treatment such as prescribing. Aftercare suggests that the important part of treatment is the prescription and the clinical interventions, with less important care to follow from the main (clinical) intervention. People will tend to stay in treatment when drug free to continue their recovery plan to successful conclusion. Relapse prevention is one component of their recovery planning. Chapter 4: psychosocial components of treatment Add section number (where relevant) Comments Insert each new comment in a new row 4.1 Psycho-social interventions should be the mainstay for all treatment, not just stimulant cannabis or hallucinogen presentations. This demonstrates some bias towards prescribing for opiate users, as there is no approved substitute prescribing for the other drugs. It reads as though Psychoactive interventions are less relevant to opioid prescribees, or opiate users who are not prescribed ORT Incorporate the relevant NTA guidance as well as NICE on this Date September

5 section Advice should be verbal and written leaflets about drugs and effects as well as leaflets on different treatment interventions such as ORT to reinforce the messages repeatedly Seems written from the perspective of a specialist psychiatrist. ECT would never be a treatment of choice in a drug & alcohol service. Access to mental health services usually limited to those with severe & enduring mental illness these days, with Dual Diagnosis services poorly developed. NHS mental healthbased treatment services less common now and a more open market for providers not linked to NHS providers. Emphasise the things a D & A service can deliver. Encourage better local development of a dual diagnosis approach between services & joint commissioning between Local Authority DAATs and local mental health commissioners. Chapter 5: pharmacological interventions 5.1 The opening section should contain a strong reference to the need for an overarching governance framework to ensure the safe use & management of CD prescribing and supply that complies with existing regulation. PCTs can no longer take on this role for D & A commissioners or providers. NHSE & CQC guidance should be mentioned. Also mention the role of the Accountable Officer for CDs in each locality and provider Emphasise the importance of clear communication between clinicians involved in any care plan especially where there may be both specialist prescriber and GP or psychiatrist prescribing of psycho-active drugs, e.g. opioid prescription from specialist prescriber and benzodiazepines/anti-depressants/pain relief prescribed by GP/psychiatrist. Routine & reliable communications in both directions should be the norm Guidance required relating to use of ECG reports in monitoring high dose methadone In response to failures to attend or engage in treatment appointments, it may be useful to reduce the prescription in a planned fashion rather than sudden cessation or exclusion. 5.6 Maintenance prescribing is still an important component of treatment and is supported with a relatively robust evidence base. Injectables are still in use for a small number of people in need. This section should remain intact. Chapter 6: health considerations We have no comments or amendments to propose here. Chapter 7: specific treatment situations and populations 7.1 Approaches to dual diagnosis such as severe mental ill health or chronic pain will require multi-agency (rather than multidisciplinary) interventions more commonly now since recent changes separated D & A commissioning from mainstream health commissioning, and provision widened to any Date September

6 competent provider. Encourage better local development of a dual diagnosis approach between services & joint commissioning between Local Authority DAATs and local mental health commissioners Needs updating following more recent CJ developments and Transforming Rehabilitation There is little difference between CPA promoted here, and the approach outlined in Models of Care (NTA 2003/2006). Both are capable of delivering complex interventions and effective risk management YP s drug & alcohol use has become much more complex with internet sales of benzodiazepines and wide availability of new psycho-active substances with unpredictable effects. Often a wide range of drugs and alcohol used together. Symptomatic management should be emphasised. YP are using more prescribed drugs, also found in parents drug cabinets, or via internet. Mental health issues are of increasing concern, with poor joint work with CAMHS services in many cases. Changes to NHS have separated many D & A services from YP mental health provision even more. Transition to adult services needs special emphasis to ensure retention in treatment. Encourage GPs to refer to specialist services rather than work alone. Simple issue of anti-depressants may not be helpful. Detailed assessment and engagement likely to offer better results and reduce harm. 7.8 A very helpful section that needs stronger emphasis, particularly when considering an ageing treatment population. Joint working is still very difficult to get right, and recent NHS changes are likely to hamper good local arrangements. Encourage multi-agency agreements and specialist working groups to keep developments on track. Question 3: Are there gaps in the current guidelines where additional advice is needed? (provide references/links where possible) General Incorporate New psycho-active substances guidance. 7.5 Include cormorbid Adult Attention Deficit Disorder and drug/alcohol dependency. 2.1 Each LA must have in place an effective & inclusive governance framework to support commissioned clinical interventions, particularly the prescribing of controlled drugs. Date September

7 Appendix 1 CIOS DAAT Consultation Angela Andrews Senior Primary Care Development Manager, DAAT Anna Whitton Regional Manager, Addaction Bruce Arnot Accountable Officer and Lead Nurse, Addaction Cornwall Carol Mitchell Drugs Liaison Officer, Devon & Cornwall Police Dalia Morgenstern Day Lewis Pharmacy/Local Pharmaceutical Committee David Ninnis UFO (Service User Forum) Georgina Praed Deputy Head of Prescribing and Medicines Management, NHS Kernow Graham Brack Deputy Accountable Officer for Controlled Drugs, NHS England Ian Gethin Local Medical Council Jeff Crowther Accountable Officer, Boswyns Residential Unit Jeremy Booker Manager, Bosence Farm/Boswyns Kerry St Leger DAAT Prescription Only Medicines lead Kim Hager Joint Commissioning Manager, CIOSDAAT Marion Barton Social Inclusion Officer, DAAT Michelle McLeavy Area Manager, Addaction Nicky Crofts UFO (Service User Forum) Phil Yelling LPC (Local Pharmaceutical Committee) Rupert White Specialist Consultant, Addaction Russ Hayton Clinical Governance Lead, DAAT Sid Willett Drug Related Death Prevention Co-ordinator, DAAT Steve Dredge Drugs Liaison Officer, Devon & Cornwall Police Kim Hager and Russ Hayton Cornwall & Isles of Scilly Drug and Alcohol Action Team Helford House, May Court, Truro Industrial Estate, Threemilestone, TR4 9LD If you would like this information in another format please contact: Cornwall Council County Hall Treyew Road Truro TR1 3AY Telephone: enquiries@cornwall.gov.uk Date September