More Than Detox: The Role of the IPU

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More Than DetoxThe Role of the IPU

• Dr Francis Keaney

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Outline

• Existing IPU provision
• Problems with the current situation
• The SCAN Consensus Group
• Summary

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National Inpatient Drug Treatment Survey

• August/September 2004

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Definitions

• Inpatient Treatment Service
• Any service located in England that has offered
  at least one planned medically assisted
  detoxification to a person using prescribed or
  illicit drugs (excluding alcohol) in the past year

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Overall findings

• Estimated 10,700 admissions in the year 2003/4
  into beds purchased for drug detoxification

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Overall Findings

• Limited length of stay
• Poor buildings
• Staffing problems
• Range of practice procedures
• No consensus on medical or psychosocial
  management
• Limited integration into the wider treatment
  system
• Poor links to aftercare
• NHS Specialist vs. NHS General vs. Rehab/Private

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Recommendations

• Purchasing a few beds on a psychiatric ward does
  not provide the comprehensive service available
  from specialist units
• Inpatient services should be encouraged to
  consider providing more than just detoxification
• The need for staff with specialist skills to work
  in inpatient services should be recognised
• All inpatient services must be integrated into
  the wider treatment system, and aftercare should
  be considered and planned prior to admission
• Minimum standards for IPUs should be drawn up and
  all units should be regularly inspected

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Recommendations

• The data from this survey could be used to
  inform an expert advisory in producing
  recommendations for a model inpatient service

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The SCAN Consensus ProjectScope

• What are the aims and objectives of inpatient
  treatment?
• What are the appropriate elements of treatment?
• How should they be delivered?
• Who needs them?
• How should they be integrated into the system of
  care?

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The SCAN Consensus ProjectProcess

• Working Group
• Steering Group
• Feedback from Psychiatrists, GPs, IPU managers,
  nursing staff, non-statutory service providers,
  pharmacists, service users

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Definition of an IPU

• Treatment involving 24-hour cover from a
  multidisciplinary clinical team with specialist
  training in managing addictive behaviours
• IPU treatment programmes include
• a range of prescribing and psychosocial
  interventions
• physical and mental health assessment
• harm reduction interventions
• relapse prevention work

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Definition of an IPU

• Medically-monitored treatment
• provided in non-acute medical settings
• Lower levels of dependence and without serious
  co-morbidity
• Medically-managed treatment
• Provided in a hospital environment
• Higher levels of dependence and
  physical/psychiatric co-morbidity

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The IPU and the wider treatment system

• Treatment should be individualised and
  assessment-driven, using care planning as a key
  implementation tool
• Good treatment planning combines modality
  matching with placement matching
• A care plan developed at a tier 2 or tier 3 level
  should use an IPU if this is the most suitable
  place to achieve a particular goal efficiently
  and successfully

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The Place of the IPU in the Treatment System
ASSESSMENT
STABILISATION
ASSISTED WITHDRAWAL
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The key features of an IPU

• Provides medically-managed care 24 hours/day
• Treatment is based on a pre-admission plan of
  care
• Staffed by a specialist multidisciplinary team
• Treatment is individually tailored, flexible, and
  makes use of a menu of pharmacological,
  psychological and social interventions
• The resources of a general acute care or
  psychiatric hospital are available - may include
  medical, surgical, antenatal, dental, dietary, or
  pharmacy advice
• The treatment programme incorporates activities
  beyond the medical or psychological treatment
  process (e.g. employment, housing, social
  activities)
• Treatment incorporates policies and procedures
  that set boundaries on behaviour whilst enabling
  patients to be treated in an empathic manner

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The core work of an IPUAssessment

• Substance use
• Physical health
• Mental health

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The core work of an IPUStabilisation

• Dose titration
• Injectable opioid medication
• Stabilisation on maintenance therapy
• Combination assisted withdrawal and stabilisation

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The core work of an IPUAssisted withdrawal

• The first step in a longer treatment process
• Needs careful attention to preparation and
  aftercare
• Effective strategies for managing
• Alcohol
• Opioids
• Stimulants
• Benzodiazepines
• Combinations of the above

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Other important functions

• Psychological interventions
• Other activities
• Harm reduction issues
• Testing for vaccinating against BBV
• Training in drug overdose prevention
• Prevention of WKS
• Healthy lifestyle advice
• Access to dental treatment
• Relapse prevention work

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Preparation for admission

• An information pack describing the unit and the
  treatment processes offered
• Liaison with referring agencies, the patient and
  their carers to establish clear goals of the
  admission and approximate likely duration
• An initial assessment done prior to admission by
  a member of the inpatient service
• Pre-admission education and counselling work is
  essential to optimise potential benefits from the
  period of IPU admission
• Advance consideration of funding, travel and
  other issues

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Link to post-discharge care

• The length of treatment should be determined by
  patient need
• A choice of care packages should be available
• The system must be flexible, as the patients
  goals often change
• Provision needs to include both abstinence and
  non-abstinence based settings
• Referring agencies should be actively involved
  before, during and after an IPU admission
• There is also a role for staff attached to the
  IPU in facilitating continuity of care
• Involve the patients family and wider social
  network in their IPU treatment plan

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Staffing

• The service provided by an IPU is dependent on
  skilled and motivated staff
• In NHS settings a specialist doctor will provide
  clinical leadership, but management leadership
  may come from any other professional group
• Configuration of the clinical team depends on
• available financial resources
• the ability to recruit specialist professional
  staff
• the needs of the patient group served by the
  inpatient service
• the goals of treatment.

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Environment

• There may be advantages if
• beds for patients with primary alcohol and
  primary drug problems are separated
• beds for assessment/stabilisation work and
  assisted withdrawal programmes are separated
• Local issues such as the size of the unit, its
  location, and its catchment area population will
  influence the exact arrangement
• Ideally wards within IPUs should have no more
  than 15 beds

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Environment

• A ratio of 15 beds (for both patients with
  primary alcohol and drug problems) per half a
  million total population is appropriate
• Commissioning arrangements will vary depending on
  location
• cities with a population of 250,000 1 million
  may be well suited to having a single standalone
  unit
• Large conurbations will require several large
  units in order to make access as easy as possible
  
• Large rural areas may need a hybrid approach

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Environment

• IPUs should ideally be located in or near to
  General Hospitals
• IPUs should be as spacious as possible, with
  outdoor space available
• Consideration should be given to providing
  female-only units or female-only sections of
  mixed units

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Environment

• All units should have
• well equipped clinical examination and consulting
  rooms ensuring privacy
• a supervised urine testing room
• a dispensing room with a way of separating staff
  from patients during dispensing
• a large group room
• a room for family visits (including play
  equipment)
• designated staff room with personal lockers,
  shower and toilet facilities and an area for
  refreshments and private time
• wheelchair access

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Other recommendations

• Training
• Service user and carer perspective
• Policies and procedures
• Special populations
• Assessing the efficacy of IPUs

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Summary

• Medically-managed service for severe problems
• The effective delivery of elements of a
  community-based care plan
• More than detox
• Close ties to referring agencies and
  post-discharge care
• Recommendations about staffing, training and the
  physical environment

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Training

• DANOS principles should be adapted to develop
  specific competencies for specialist IPU staff
• Apprenticeship and rotational training schemes
  for junior staff that incorporate IPU experience
  may be useful
• Staff rotation between inpatient and community
  services is advantageous
• Service users and carers should be involved in
  in-house training where possible
• Regular clinical supervision is essential for the
  delivery of evidence-based psychosocial
  interventions

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Service user and carer perspective

• Provide info for patients about the unit,
  treatment pathways, policies expectations
• Service users should have access to an IPU with
  the full range of facilities and should expect to
  have a comprehensive post-discharge plan
• Each service user must have a role in drawing up
  and reviewing their care plan
• Facilitate user support groups
• Support ex-service user involvement as volunteers
  with routes into paid employment
• Regular patient satisfaction surveys and act on
  the results

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Policies and procedures

• Access to visitors
• Use of illicit drugs, alcohol tobacco
• Drug testing
• Unplanned discharge
• Police involvement
• Re-admission procedures
• Child protection issues
• Ex-users and volunteers