Nelson Alcohol and Other Drug Nelson Alcohol and Other Drug ServiceService

GP CME Presentation

March 2009

What do the AOD clinic do?What do the AOD clinic do?

• Specialist assessment of alcohol and other drug disorders• Comprehensive assessment and diagnosis using DSM1V

criteria• Addiction medicine specialists• Use of specific pharmacotherapy• Co-existing disorder management• Therapeutic interventions• Family/whanau support• Specific Youth service• Detox service• Opioid substitution programme• GP Liaison for opioid substitution via GPs• Education• Research

What drugs are most commonly What drugs are most commonly used?used?

• Nicotine• Alcohol• Cannabis • Stimulants• Benzodiazepines• Opiates• Hallucinogens• Solvents/gasses

What is Detox?What is Detox?

“Detoxification refers to the process by which the effects of opiate drugs are

eliminated from opiate dependent users in a safe and effective manner, such

that withdrawal symptoms are minimised. (WHO 2006)

“The history of the treatment of narcotic withdrawal is a long and dishonourable one....”Kleber H.D. et.al. The treatment of Narcotic withdrawal: A Historical Review. J Clin Psych. 43:6(Sec 2)- June 1982

• Belladonna treatments

• Peptization and water Balance Treatments

• Bromide sleep treatment

• Lipoid Treatments• Endocrine

treatments• Immunity

Treatments• Accupunture• Vitamin C

•Abrupt and rapid withdrawal•Convulsive therapy•Hibernation therapy•Methadone•Phenothiazines•Diphenoxylate•Propanalol•Proxyphene•Naloxone precipitated withdrawal

Opiate Withdrawal ManagementOpiate Withdrawal Management

• Buprenorphine v traditional ‘cold turkey’• Symptomatic relief• COWS done daily• Management of the most difficult to deal

with symptoms. Insomnia, restless legs, agitation

• Protracted withdrawal syndrome

Protracted Withdrawal?Protracted Withdrawal?

• “While the literature would support the continuation of physical and subjective abnormalities beyond the acute withdrawal period of alcohol and opiates....protracted withdrawal has not been conclusively demonstrated because of methodological limitations” Satel SL et.al. Should protracted withdrawal from drugs be included in DSM IV? AM J Psych. 150:695-704,1993.

Choice of opiate agonistChoice of opiate agonist

• Both methadone and buprenorphine have been found to be effective in the treatment of opiate withdrawal though the evidence for methadone has a greater research base

• There is evidence that buprenorphine has a shorter period of withdrawal and a greater rate of retention in treatment. [1] Gowing L, Ali, R, White, J. Buprenorphine for the management of opioid withdrawal. Cochrane database of systematic reviews 2006. Issue 2

• [2] Amato et.al. Methadone at tapered doses for the management of opiate withdrawal (Review) Cochrane database of systematic reviews 2005, issue three.

Detox OutcomesDetox Outcomes

• 149 patients admitted to an inpatient detoxification• Detoxification/individual therapy/group therapy

• 2-3 years later 5 died• 54%continuing to use illicit drugs• 57% on maintenance• 25% abstinent within last month

• Abstinence associated with • completion of in-patient program• attendance at aftercare• not using IV• absence of family history of using

Smyth et.al. In-patient treatment of opiate dependence: medium term follow-up outcomes. British Journal of Psychiatry. (2005), 187, 360-365.

Daryle Deering et al. NAC ‘Barriers to Care- A Service Users Perspective’ 2008

Table 6: Number of clients receiving opioid substitution treatment in New Zealand via Specialist Services (n = 18)

Services/DHB Total (n = 4400)

Specialist Service (n = 3463)

GP Authority (n = 932)

% GP Authority

Auckland 1089 809 280 26 Christchurch 565 334 231 40 Wellington 374 306 68 18 Nelson/Malborough 338 265 73 22 Otago 317 282 35 11 Midcentral 305 266 39 13 Waikato 289 260 29 10 Northland 215 177 38 18 Taranaki 140 103 37 26 Napier Hawkes Bay 123 95 28 23 Wanganui 113 87 26 23 Tauranga 107 102 5 5 Wairarapa 91 85 6 7 Southland 91 81 10 11 Timaru 81 64 17 21 Lakes DHB 69 67 2 3 West Coast DHB 63 51 12 19 Tairawhiti 30 29 1 3 Total 4400 3463 937 21%

Barriers To Transfer Of Barriers To Transfer Of Clients-Primary CareClients-Primary Care

All 18 services identified barriers

• GP availability (61%)

• Stigma (39%)

• Cost to clients (66%)

• Clients preferring clinic (39%)

• Clients not ready (39%)

• Service staffing/attitude related (44%)• Deering et al 2008

GP liaison for methadone GP liaison for methadone prescribingprescribing

• Criteria for GP prescribing• Process for transfer• Ongoing monitoring• Responsibility of care• What happens when the wheels fall off?

Criteria for GP prescribingCriteria for GP prescribing

• No concerns re behaviour• No unresolved issues re misuse• Illicit drug use not detected in UDS• Client has complied to requirements of

O.S.T.P.• No recent illegal activities• Client has engaged with participating GP• Stable dosage of methadone • Takeaway arrangements established

Process for transferProcess for transfer

• Contact with client’s G.P.• Authorisation by AOD Medical Officer• Client’s comprehensive assessment

and prescribing details to G.P.• Copy of medical history and risk factor

assessment sent to G.P.

Ongoing monitoringOngoing monitoring

• Client to attend G.P. appointment once monthly for renewal of prescription.

• G.P. Liaison Clinician to meet with client at least annually.

• AOD will ask client for 2 urine drug screens a year

• G.P. Liaison Clinician liaises with client’s G.P. throughout treatment.

Responsibility of careResponsibility of care

• Overall stability of client• Injection site(s) examination• Hepatitis status• Liver function tests• HIV tests

What happens when the wheels fall What happens when the wheels fall off?off?

• Clients can be returned to Specialist Service

• G.P. Liaison Clinician is available Monday to Friday 0830 to 1700 hours

• Relevant clinical staff available if required.

Who to Contact at AODWho to Contact at AODMethadone Prescribing:Jude Burgess or Dr Lorraine Balance

Detox/withdrawal:Steph Anderson

Complex AOD/Pain/Out of hours:Dr Lee Nixon or Dr Marijke Boers

Regional Service Manager is Eileen Varley