Community and Home Detox - An overview of service provision

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1 Community and Home Detox - An overview of service provision David Prentice Clinical Charge Nurse Community and Home Detox CADS Auckland Waitemata District Health Board

2 Overview Medical Detox Services In-patient Detoxification Unit (IPU) and Community and Home Detox Service (CHDS) Substances we work with CHDS Walk in Clinic Community withdrawal management Relapse prevention initiatives

3 Medical Detoxification Service Philosophy Biosychosocial model Harm minimisation Family inclusive Strengths based Evidence based Multidisciplinary team approach Two teams Detox In-patient Unit (IPU) and Community and Home Detox Service (CHDS)

4 Medical Detoxification Service IPU Residential setting 11 beds Short stay, approximately 7 days 24 hour medical monitoring Relapse prevention groups CHDS Medical monitoring in home or community Walk in clinic Consultation/advice to health professionals

5 Medical Detoxification Service Referral Process Clients can self refer via CADS website, Detox Referral Line, CHDS Walk in Clinic Referrals received from CADS clinicians, other health professionals and the NGO addiction sector Friends/family/significant others can not refer clients All referrals received by the Detox Referral Coordinator and then discussed with senior detox team on a daily basis Decision then made as to whether client requires inpatient or community detox

6 Substances we work with Alcohol Benzodiazepines Opioids In 2011 CHDS completed 614 assessments 2455 face to face client contacts Approximately 150 community based detoxes 40% alcohol withdrawal 40% benzo stabilisation/reductions 20% opioid detoxes

7 CHDS Walk in Clinic The CHDS clinic is nurse led with multidisciplinary team support Operates Monday - Friday from 10AM - 1PM No appointment necessary Purpose of the clinic to assess for physical dependency and then develop a safe detox plan Clients often present in crisis with complex needs Risk management is an important part of the process All assessments are discussed at the daily detox referral meeting where the detox plan is confirmed Plan is communicated back to the client and the process of preparing for detox begins

8 Community withdrawal management Alcohol withdrawal Diazepam mainly used for alcohol withdrawal Oxazepam used as alternative if diazepam contraindicated 60mg diazepam daily maximum is prescribed If client requires more than 60mg then an inpatient detox is indicated Set regimens of diazepam used depending on level of use

9 Community Withdrawal management Alcohol withdrawal Diazepam prescribed by either Detox Medical Officer or GP Use of CIWA scale for measuring withdrawal symptoms Typical community based alcohol detox is between 4-6 days Clients visited daily to make sure medication matches level of withdrawal, monitor risk and work on relapse prevention Clients progress discussed at weekly MDT meeting

10 Community Withdrawal management Benzodiazepine stabilisation/reduction Increasing numbers of clients are presenting with benzo dependence Clients are stabilised onto diazepam for generally a two week period CHDS team work closely with GP S around prescribing management. Often Detox Medical Officer initiates prescribing and GP continues to prescribe after stabilisation process is completed

11 Community Withdrawal management Benzodiazepine stabilisation/reduction Length of reductions vary depending on level of use beforehand and dose of diazepam CHDS team see client weekly or fortnightly during the reduction to monitor benzo withdrawal symptoms Use of Detox Physiotherapist for withdrawal symptom/anxiety/sleep management support The speed of reduction depends on how clients cope with withdrawal symptoms flexibility in dosing is the key

12 Community Withdrawal management Opioid withdrawal Morphine, methadone, codeine, nurofen plus, tramadol, DHC, Oxycodone are main substances that clients use Buprenorphine (suboxone) is used as withdrawal medication Duration of suboxone detox is 6-8 days Often clients need to reduce use prior to detox starting Clients then need to be on a stable dose for 1-2 weeks before detox starts

13 Community Withdrawal management Opioid withdrawal Suboxone is a specialist only medication, GP S cannot prescribe it Client has to pay for cost of suboxone. Average cost is $52 per detox Detox Physiotherapist is key to withdrawal symptom management. Use of acupuncture reduces intensity of withdrawal Use SOWS scale to monitor withdrawal symptoms Post suboxone withdrawal typically lasts 2-4 weeks but can be longer

14 Relapse prevention initiatives Up to 50% of CHDS clients have little or no follow up post detox CHDS team is developing skills and experience in CBT and MI approaches to offer clients a more robust detox experience Use of client centred goal planning to realise potential Goal planning focuses on strengths as well as problems Goal planning is a powerful tool in relapse prevention

15 Relapse prevention initiatives Intensive Community Support (ICS) Programme Suitable for long term chronic relapsing alcohol clients Clients have complex health needs and multiple risks CHDS team provide long term case management Aim is to limit the number of detoxes clients have and to increase their quality of life Goal planning, CBT approaches and MI are key to enhancing relapse prevention for this client group

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