DETOXING THE DEPENDENT DRINKER ON METHADONE JEFF FERNANDEZ NURSE CONSULTANT FOR SUBSTANCE MISUSE ISLINGTON
BACKGROUND Substance misuse services Prescribing conducted by: IDASS PCADS ISIS Tier two provision: Daap ( Cri) and Cranstoun Substitute prescribing mainly using buprenorphine and methadone Diazepam detoxifications Alcohol detoxifications are minimal
Drug and Alcohol Treatment The main presentation to services is dependent drinking and dependency on opiates ( Mainly heroin) and crack Problems with this are physical and mental health is affected. IV use more problematic for physical health Dependent drinker on its own has more of a psychological approach with talking therapies MI and CBT used in methadone treatment as well but linked to engagement Outcomes better in alcohol rather than drug dependency Alcohol and drug dependency also a common feature This presentation looks at what can be done
GAPS IN TREATMENT National Treatment Agency Waiting times in early 2000 and to fast track treatment Now with a the current government the emphasis is on recovery Not yet defined well enough But this may just emphasize the increasing role of detoxification in drug services
GAPS IN TREATMENT Growing presentation in Islington is the maintenance of methadone patients who develop dependent patterns on alcohol There are many risks associated with this with the main one being: Increases the risk of overdose However, detoxification of alcohol should be considered but is often not.
Alcohol and drug dependency This presentation is very common in substance misuse services This presentation looks at what can be done in this area and how substance misuse look to treatment complex cases.
GAPS IN TREATMENT Study to increase the level of alcohol detoxification on methadone maintenance patients Conducted at ISIS Detoxification of own clients in the service and some from PCADS ISIS had access to seeing patients everyday and hence the reason this service was used for alcohol detoxifications Pilot conducted by independent nurse prescriber.
Nurse prescribing Independent prescribing Supplementary prescribing In the area of substance misuse with controlled drugs prescribed as substitute prescribing buprenorphine and methadone are prescribed by nurses as supplementary. Alcohol detoxifications are prescribed as independent by nurses in the area of substances misuse. Alcohol detoxes use Librium/chlordiazepoxide Nurse prescribing in Islington covered under a Standard Operational Procedure. Also alcohol detoxification covered
Nurse Prescribing Nurse Prescribing initiated to increase access to treatment and also ease the burden on GP s and doctors. University courses untaken for Non-medical prescribing Further verification to prescribe for nurses in their areas of competence and agreed locally but their employers Nurses can only prescribe on pads which show their details : The dispensing pharmacist will need to be sure that the prescriber has qualified as a nurse or pharmacist independent prescriber. The prescription form will indicate whether a prescriber is a nurse or pharmacist independent prescriber.
DETOXIFICATION An area where nurse prescribing can increase the patient s access to treatment. In substance misuse there was a borough wide need to increase the level of detoxifications across the borough. Librium used as safer and avoids respiratory depression Librium prescribed by the clinician lead and also Lead nurse Dosing regimes start from 40 mgs QDS but there is flexibility Patient seen every day Disulfiram used to aid the client achieving dry time
INCLUSION CRITERIA The criteria were needed to avoid increasing the risk of overdose for some individuals Patient has been on methadone for six months at least No history of fits Has been compliant with substitute prescribing regime Has achieved some stability on methadone or measurable benefits i.e use of heroin dropping from every day to once a week
CRITERIA Epilepsy History of previous treatment for alcohol: History of any previous detoxification regimes completed: It is important to ascertain whether any dry time had been achieved by the patient after detox. The more often this is the case the better the outcome. History of any mental health issues which could compromise the detox regime: Recent Liver Function tests:
CRITERIA Client is not dependent on benzodiazepines Client is willing to detox off alcohol LFT s indicate this is safe and therefore GGT and AST readings are not be severe Client consents to regime and is seen everyday. Consents to disulfiram for a minimum of six weeks.
CRITERIA History of previous treatment for alcohol: This is a pertinent question with a certain client group. With the ISIS cohort, the more detoxification patient has had, the more likely they were to complete the detox successfully. Arguably the more detoxifications undertaken, the more insightful the client is ( NTA, 2002)
METHODOLOGY Fifteen clients detoxed and they were from ISIS and PCADS The location of the patients had an influence on the outcome Results showed from the case study illustrates what was learnt from the pilot. This has now been adopted at Isis to increase the levels of detoxification off alcohol for methadone dependent patients.
MEDICATION Medication Chlordiazepoxide in 5mg caps is prescribed according to the following regime, though some flexibility obtains: Men 10-30mgs Q.D.S. (four times a day), reducing dose over 5 days Women: 10-20mgs Q.D.S., reducing dose over 5 days A two weeks prescription of Thiamine 100mg bd and Multi B Compound, which can be further prescribed if necessary by an independent prescriber. Where appropriate, night sedation can be prescribed for a two week period. Pabrinex can also be prescribed. Reference's: CKS summaries: Local guidelines on intranet: Different to the BNF guidance but used by local specialist services such as ISATS
CRITERIA 1) Length of treatment history: Primary care patients had a longer history of treatment than other patients at ISIS referred for an alcohol detoxification. 2) Engagement: The primary care patients were better engaged in services and had more exposure to health care than other ISIS referrals. 3) Stability: The primary care patients were more stable overall in their drug use and had minimal use on top of their methadone doses as opposed to the ISIS patients.
CASE STUDY Chris is 44 years of age and has lived in Islington since he was a child. He has been in treatment for drug dependency since 2000 when he admitted to himself he had a problem with heroin. He was at a specialist service for drugs initially and was transferred to shared care when he was seen as more stable on his dose of methadone (Opiate substitute) and is seen in primary care by a specialist drugs nurse and the GP. He has been drinking heavily for the last seven years and feels his alcohol grew into a dependent pattern gradually. He has been drinking every day for the last two years and wants to stop.
CASE STUDY According to one assessment he had been drinking around 10-15 units of alcohol a day while taking 70 mgs of methadone. He was not topping up with street drugs and described himself as a stable patient apart from his alcohol use. On a previous occasion he had been on an in patient detox regime after which he had stayed dry for two weeks. He had some insight into how a detoxification regime off alcohol would work. He also knew how easy it was to relapse, and seemed to be aware of the problems and triggers that he would need to deal with when attempting to stay dry. He was offered disulfiram post- detoxification, something he had never been offered or used before, and he felt this would be useful.
OUTCOME Completed the detoxification successfully Was seen every day through the detox regime Started on disulfiram and stayed dry for six weeks Relapsed but reduced his drinking to 5 units a day Will detox again when he feels ready
CONCLUSION To date the specialist nurse at the ISIS in Islington has worked with fifty alcohol detoxification cases. Most cases were referred by primary and specialist care services. Most primary care referrals were able to stay dry with disulfiram, but patients referred from specialist services did not stay dry post-detoxification beyond two weeks.