A Nurse Practitioner led opiate substitution prescribing clinic The

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1 A Nurse Practitioner led opiate substitution prescribing clinic The X First Forty Fifty Four Stephen Ling Nurse Practitioner Drug and Alcohol, Hunter New England Local Health District Conjoint Teacher, University of Newcastle, Faculty of Health, School of Nursing and Midwifery

2 A Nurse Led Opiate Treatment Clinic Endorsed as a Nurse Practitioner June 2004 Completion of the Opiate Treatment Accreditation Course authorities to prescribe opiate substitution treatment prior to the commencement of the clinic An area of need identified by the Drug and Alcohol Clinical Services management Negotiation between services

3 Commenced September 2011 Predominantly Justice Health patients Also other patients moved to the clinic 1 x 4 hour session/week 1 hour consultation new patients 30 minute follow up appointments 30 minute follow up appointments for other prescribers patients

4 1 Registered Nurse to case manage Staff Specialist availability and team case review meetings

5 Opiate Substitution Treatment NSW/Aus The Commonwealth Government Department of Health and Ageing: supplies methadone and buprenorphine (free of charge) pays for services by doctors (Medicare) approves formulation and registration of products Therapeutic Goods Administration, also responsible for recall of faulty products national policies and guidelines on the use of methadone and buprenorphine national policies and guidelines on training tracks use of narcotics.

6 The NSW State Government The Poisons and Therapeutic Goods Act 1966 (NSW) and Regulations (2002) provide for: the authorisation of medical practitioners and nurse practitioners as prescribers of opioid treatments the review, amendment, and cancellation of medical practitioners or nurse practitioners authorities to prescribe

7 procedures to allow drug dependent patients access to treatment licensing of private clinics investigation of complaints regarding prescribing and the professional behaviour of prescribers regulation of labelling, packing, storage, prescription and supply of products record-keeping on the use of drugs of addiction.

8 Initial Interview I am a Nurse Practitioner not a Doctor Substance use history Including current treatment Health history and examination Including Hepatitis C, mental health, allergies, other medications, and examination of injection sites, signs of intoxication/withdrawal (NO EXAMINATION TABLE) Social situation and supports Authority to prescribe Development of a treatment plan and prescription Oh, and you need a GP and tell them of your treatment!

9 Results September 2011 June 2013 Mixed retrospective prospective audit 54 patients to date 5 signed prior to commencement of the clinic 49 since commencing the clinic

10 Gender of patients 13 male female 41

11 Reason for treatment opiate dependent and Justice health Justice health + pregnant chronic pain other

12 Other Conditions Perforated duodenal ulcer and NSAID S+codeine Gastric ulcers and NSAID S+codeine Mitral valve replacement and over the counter analgesics Infective endocarditis Acute pain x 4 Critically low albumin Septic knee Self harm Needle tip as a foreign body Transfer from satellite clinic

13 Treatment type Methadone Suboxone Subutex

14 Origin and treatment type Buprenorphine Methadone 5 0 Justice health Justice health + pregnant chronic pain other

15 What has happened to the patients? Still prescribing 4 transferred to another prescriber at clinic 5 transferred to a satellite clinic 6 external prescriber 3 request to cease 7 return to JH 6 fail to attend 1 Involuntary reduction

16 42 Methadone mg 12 Buprenorphine mg

17 Other Events 3 patients converted from methadone to Suboxone 1 patient reduced to cessation (opioid bowel syndrome) 1 patient ceased to attend before completing reduction 1 transferred to another prescriber at the clinic 1 patient converted from Subutex to methadone 1 patient converted from Suboxone to methadone

18 The sky hasn t fallen One patient has died had ceased treatment 1 adverse drug event not critical

19 Request to Cease 1 patient couldn t afford treatment 1 patient didn t like the treatment 1 patient on medical grounds

20 Patients Who Jumped 1 patient failed to attend for change in dosing point 1 patient? found a prescriber of opioid analgesics 1 patient? to escape Community Services 1 patient never really engaged and acutely suicidal 1 described amphetamines as drug of choice anyway 1 patient? due to serving out parole period

21 Lessons learnt Patients released from Justice Health Compliance Behaviour The hazards of over the counter analgesics Buprenorphine and persistent pain Defining stability Opiate dependence treatment and benzodiazepines Attendance at Friday clinics? Signing scripts for the invisible patient

22 Questions and issues Why are there more patients on methadone? Why have people stopped treatment or changed prescriber? Am I doing something wrong? Has there been value in having a Nurse Practitioner led clinic? Do we need more drug and alcohol Nurse Practitioners?

23 References NSW Health. (2006). Opioid Treatment Program: Clinical Guidelines for methadone and buprenorphine treatment 6/pdf/GL2006_019.pdf

24 Thanks to the staff of Newcastle Pharmacotherapy Service and the John Hunter Hospital

25 THANK YOU

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