SPECIALIST COMMUNITY ADDICTION SERVICE

1
SPECIALIST COMMUNITYADDICTION SERVICE

• Services for drug users throughout Oxfordshire
• Jill Lark
  RGN
• Addiction
  Nurse Specialist
• SCAS

2
AREAS TO BE COVERED

• Introduction
• Who's Who?
• Terminology
• Different Drugs
• Clinical Management
• Drug Paraphernalia
• Other Services
• Vignettes

3
WHO AM I?

• RGN 22 years trained in Oxford
• ICU angiography
• Transplantation
• New Zealand - Private
• United Kingdom - NHS
• Addictions Diploma St Georges
• 7 Years Addictions (including 5 years homeless
  network)?

4
WHOSE WHO

• National Treatment Agency
• Drug Alcohol Action Team
• Specialist Community Addiction Service
• Shared Care (DAAT PCT)?

5
WHAT IS SHARED CARE?

• Shared Care Model promotes the shared clinical
  care of a patient by the GP or GpwSI, SCAS Nurse
  Pharmacist which will usually involve
  substitute prescribing of either methadone or
  Subutex

6
THE AIM OF SHARED CARE

• The principle aim of shared care in the clinical
  context, is to provide a comprehensive service to
  drug users that will reduce drug related harm and
  the potential for death.

7
OBJECTIVES OF SHARED CARE

• Accessible consistent service
• Promote best practice
• Develop good working relationships
• Provide consistent code of practice for
  prescribing and management
• Provide care for the majority of drug users

8
WHY SHARED CARE?

• Medical Practitioners should not prescribe in
  isolation, but should seek to liaise with other
  professionals who will be able to help with
  factors contributing to a individual's drug
  misuse.
• 
  DoH 1999

9
WHO IS SHARED CARE?

• General Practitioners
• GP's with a Special Interest (GPwSI)?
• SCAS Nurses
• Community Pharmacists

10
CITY CENTRE v COUNTY

• Consultant
• Dr Andrew McBride
• Clinical Nurse Lead
• Sam Clarke
• 07788754345
• 11 GP surgeries

• Consultant
• Dr Gail Critchlow
• Clinical Nurse Lead
• Mark Stevens
• 07788754352
• 15 GPs
• 4 Resource Centres
• Abingdon, Didcot, Witney Bicester

11
WHY PRESCRIBE?

• Engage patient in treatment
• Reduce or prevent withdrawal
• Reduce criminal activity
• Reduce unsafe sexual practices
• Reduce dependence on drug using lifestyle
• Opportunity to stabilise drug intake
• Reduce unsafe injecting practice/BBV

12
BENEFITS OF PRESCRIBING IN PRIMARY CARE

• Treatment accessible relevant
• Recognises multi-factorial nature of drug use ?
• Minimises the risks of isolated practitioners
• Cost effective
• Patients treated in normal primary care setting

13
REASONS WHY PEOPLE

• START
• Mental Health Problems
• Life Crisis
• Abuse/care system
• Boredom
• Women - partners

• STOP
• Age life begins at 30
• Rock Bottom
• Physical Crisis
• Boredom
• Never

14
THE CYCLE OF CHANGE

• Ambivalence
• Contemplation
• Action
• Maintenance
• Relapse
• 
  Prochaska DiClemente

15
ADDICTION v DEPENDENCE

• Crime
• Social isolation/family rejection
• Reduced self care/nutrition
• Reduced sleep/reduced mood
• Unemployment
• Chaos
• BBV DVT etc
• Mental Health problems
• Increased risk of self harm

• Physical and psychological

16
THE JOURNEY THROUGH ADDICTION

• Titrate
• Stabilise
• Maintain
• Reduce
• Detox
• Rehabilitation
• Recovery

17
HEROINSIGNS OF USE

• Pinpoint pupils
• Droopy eyelids
• Relaxed state
• Gouching
• Reduced cough reflex
• Reduced heart rate
• Lethargy
• Itching

• Reduced libido
• Needle marks
• Abscesses in strange places
• DVT
• Hooded Sweatshirts

18
HEROINSIGNS OF WITHDRAWAL

• Dilated Pupils
• Runny Nose/Eyes
• Yawning
• Nausea Diarrhoea
• Muscle Aches Cramps
• Goose Bumps/Shivering
• Sweating

19
ASSESSMENT

• TEST URINE NON NEGOTIABLE
• Withdrawal Signs
• Current usage
• Duration of Use
• Track Marks
• Alcohol
• Poly drug use

• Psychiatric History
• Physical Health
• Past Treatment
• Social Factors
• Weigh Them

20
INJECTING EQUIPMENT

• 2ml Plastic water ampoules are prescription only
  so packs only give glass ones
• 1ml syringe barrel will put less pressure on the
  vein, but some people will only use 2ml
  (especially groin injectors) because it will
  ruin their buzz otherwise.
• Dont underestimate the power and importance of
  the ritual of preparing etc. for drug users.
• Vitamin C is usually used with heroin as it is
  less acidic and therefore less damaging on the
  veins.

21
METHADONE v SUBUTEX

• More than 30 Daily
• Injecting
• Established habit
• Polydrug use
• Chaotic

• Less than 30 Daily
• Smoking
• Short habit
• Heroin only
• Stable

22
Substitute Prescribing

• Methadone needs to be prescribed safely to avoid
  the dangers of overdose and diversion
• STARTING METHADONE IS NEVER AN EMERGENCY
• Starting methadone without evidence of opiate
  dependency is very dangerous should never be
  done.

23
INITIATING METHADONE TREATMENT

• Methadone Mixture 1mg/ml (Not 5mg/1ml)?
• FP10 Blue Prescriptions
• Never Physeptone Tablets or IV Ampoules
• Daily supervised consumption (12 weeks)?
• START LOW GO SLOW
• First 2 weeks greatest risk of overdose

24
INITIATING SUBUTEX TREATMENT

• 8 hours after last dose of heroin
• 24-36 hours after last dose of methadone
• moderate signs of withdrawals
• Daily Supervised Consumption FP10
• Not licensed for use in pregnancy

25
NALTREXONE

• When urine clean of ALL opiates
• Check LFTs before throughout treatment
• Starting dose 25mg daily increasing to 50mg
• Double dose and take thrice weekly
• Expensive 50 tablets 90
• Naltrexone implants are NOT licensed

26
CRACK COCAINE(white, stone, rock)?

• Cocaine pure, expensive, snorted
• Freebase street cocaine that has been converted
  to a pure base by removing the hydrochloride salt
  many of the adulterants (talc,flour). End
  product is not water soluble and as such can only
  be smoked.
• Crack powdered cocaine melted with water. When
  liquid cools it is mixed with baking soda and
  cold water and then cut into small pieces which
  harden and crackle when smoked

27
CRACKSIGNS OF USE

• Increased Energy/Fast Speech/ Fidgety/Increased
  Libido
• Euphoria
• Weight Loss
• Bad Breath/Frequent licking of lips
• Anxiety/Paranoia
• Birth Defects

• Insomnia
• Respiratory Problems/Runny nose/colds/chronic
  nasal problems
• Scabs/abscesses
• Depression/Mood Swings
• Tachycardia/MI

28
TREATMENT OF CRACK USE

• Triggers
• Cravings
• Relapse Prevention
• Auricular Acupuncture
• Reflexology
• Classical music!
• Libra (Cranstoun)?
• Group Work
• 11 Work

29
PREPARING CRACK

• Washing cocaine hydrochloride with sodium
  bicarbonate good for IV use
• Washing the cocaine hydrochloride with ammonia
  produces crack cocaine. This has a better
  affinity with the lungs so better for smoking.

30
CRACK USE

• Citric acid is generally better for crack use.
• There are lots of problems associated with crack
  use. Local anaesthetic,
• Smoking crack dehydration, - cracked lips, -
  BBV
• Can use, beer tin, Lucozade bottle. Will also
  need, gum, biro, silver foil and elastic band.

31
BEFORE AFTER
32
BENZODIAZEPINESTHE POSITIVES

• Highly effective in the short term
• Rapid onset of action

33
BENZODIAZEPINES THE NEGATIVES

• Tolerance dependency develop quickly
• HUGE street value Diversion
• Rebound anxiety/insomnia
• Withdrawal symptoms fits
• Increases affects of alcohol, methadone heroin
• Risky in overdose
• Increased drug hunger/BBV/UPSI
• Poor social functioning

34
BENZODIAZEPINEWITHDRAWAL SYMPTOMS

• Cravings, perceptual distortion,phobias
• Anxiety,panic attack, poor concentration
• Crawling skin
• Ataxia/tremor
• Hypersensitivity to light,smell, touch, taste
• Dry mouth
• Diarrhoea,constipation
• Flushing,racing pulse,sweating,
• Thirst, frequency, incontinence
• Insomnia

35
BENZO REDUCTION

• Convert all benzos to equivalent dose of diazepam
• Make all changes at the same time
• Diazepam 10mg is to
• Temazepam 20mg
• Nitrazepam 10
• Lorazepam 1mg
• Oxazepam 20mg
• Chlordiazepoxide 20mg
• Rohypnol 1mg

36
BENZODIAZEPINESIN SUMMARY

• Not Licensed for opiate withdrawal
• Avoid or refer to SCAS psychiatrists
• Potentiates the affects of alcohol,heroin,methadon
  e
• Liquid Form only
• Daily Supervised Consumption on FP10 form

37
BENZODIAZEPINE OBNOXIOUSNESS RATING EVALUATION

• 10mg Just for a few days doc
• 30mg - But I really need them
• 60mg - You CANT stop them!
• 100mg What day is it?
• 200mg Patient looks like a sleeping horse
• 300mg I woke up at the police station
  having tried to steal a freezer
  from Comet

38
BORE IN ACTION
39

• DONT ENABLE THEIR CHAOS

40

• IF YOU'RE WORKING HARDER THAN YOUR PATIENT,
  THERE'S SOMETHING WRONG

41
Approximate drug detection times in urine

• Heroin
• Methadone
• Codeine
• Dihydrocodeine
• Cocaine
• Benzodiazepines
• Cannabis (acute)?
• Cannabis (chronic)?
• Ectasy
• Subutex
• Alcohol

• 1-3 days
• 1-2 days
• 2-3 days
• 4-5 days
• 12 hours 3 days
• 1 day- 3 weeks
• 2-7 days
• Up to 30 days
• 2-4 days
• 2-3 days
• 12-24 hours

42
EVOLVE

• 10-18 year olds
• Community support
• Living with Oxfordshire
• Problematic high risk use
• Access to substitute prescribing or community
  detox
• Screening advice BBV's
• Auricular acupuncture
• enquiries_at_EvolveOxon.co.uk
• 01865 723909

43
ALCOHOL DETOX

• CDZ 10 day community based treatment
• Alcoholics Anonymous
• Libra 11 Alcohol Counselling
• OR
• 1 Day Symptom Triggered Detox

44
THE MORNING AFTER
45
CRIMINAL JUSTICE SERVICES

• Probation
• HMP Bullingdon
• CARAT

• DIP
• DRIP
• SMART
• AARS

46
MENTAL HEALTH SERVICES

• Assertive Outreach Team
• Elder Stubbs
• Restore Beehive
• Elmore Team
• Mind Group Services
• Mill
• Acorn
• Gemini

• OBMH
• CMHT
• Warneford
• Littlemore
• Forensic Services
• Complex Needs
• Crisis Intervention Team

47
HEALTH SERVICES

• Hepatology Dept
• Harrison Dept
• John Warin Ward
• Barnes Unit

• A E
• Health Visitors
• Practice Nurses
• District Nurses
• Social Workers

48
HOUSING SERVICES

• Street Services Team
• O'Hanlon House
• Lucy Faithful House
• Simon House
• The Bridge

• Julian Housing
• Stonham Housing
• Mind Housing
• Response Housing

49
DAY SERVICES

• Baseline
• Libra 11
• SMART Counselling
• Womens' Service

• Wet Room
• Day Centre
• The Gap
• The Gatehouse