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Transcript
Good Prescribing to support Criminal Justice Interventions Lucy Cockayne Consultant Psychiatrist Lead Clinician NHS Fife Addiction Service Structure of the session Introduction (5 minutes) Overview of prescribing principles (20 minutes) Small group scenarios (10 minutes) Prisoner release planning The doctor won’t prescribe diazepam Continued use “on top” Cocaine and methadone A client smelling of alcohol Feedback (5 minutes) Introduction – What are the main issues? Are there Common Principles to non forensic treatment? Are there differences in practice? Write down your top 3 Write down 3 differences Why do these occur? Are these good differences or not? Group discussion What are the aims of good prescribing in a forensic setting? Alleviate suffering Reduce harm associated with drug use Reduce criminal behaviour Reduce complications of drug misuse Reduce risk of BBV transmission Complications of injecting General health Promote recovery Specific Challenges 1. For Prison Prescribing Continuity of prescription from the community Back into the community Volume of potential clients and their speed of movement through the system Tension of depth vs speed of assessment Response to drug related death data Especially for short termers Issues around loss of tolerance Cost and staffing 2. Community criminal justice prescribing Tensions within the team Differing opinions Expectations from court Treatment as more than a prescription! “First do no harm” “More than methadone” What forms of drug misuse have evidence based prescribing options? Opiates Benzodiazepines? Methadone Buprenorphine Actually no licensed prescribing- controversy over structured detoxification Alcohol Detoxification Acamprosate, naltrexone and antabuse as adjunct to abstinence Alcohol Treatments Detoxification Chlordiazepoxide (Librium) Vitamin supplementation Aids to maintaining abstinence or controlled drinking Antabuse (abstinence only) Acamprosate Naltrexone Treatments exist:- Average alcohol intake (drinks / week, TLFB) –but they’re not a “cure” * * Opiate dependence Four treatment types: Agonist eg methadone Antagonist eg naltrexone Partial agonist eg buprenorphine Symptomatic eg lofexidine Think lightbulbs! 100w vs 60w vs dead! Lightbulbs… Agonists Heroin Methadone x Partial agonist Antagonist (Blocker) x x Buprenorphine (Subutex, Suboxone) Naltrexone x WHY NOT JUST METHADONE? “If the only tool you own is a hammer, everything starts to look like a nail” Choice increases retention in treatment Choice increases patient “buy in” Different patients need different treatment Some want sedative effects Some need to be clear minded Some are at higher risk of overdose Some need to avoid drug interaction or side effects Prescribing for complications of substance misuse Important to help progress through treatment and prevent relapse Up to 40% have mental health needs that may benefit from prescribing Physical health problems common Current barriers to good quality treatment in forensic settings 1. Organisation factors Stigma Unrealistic expectations and false beliefs… Confusion between getting addicted and treating addiction and its consequences –ie cause and effect Lack of flexibility 2. Patient factors in prescribing “Motivation”? Compliance Severe dependence Complex issues Memory problems There is no single, one “best” treatment for ever and ever the best treatment is the one that suits the client at that time Where does medication fit in the treatment programme? House theory of addiction medication fills in the foundations. Foundations come first Foundations are only the start… Foundations must be strong Changes in foundations may have catastrophic effects. “Drug addiction is a chronic, relapsing brain disease” Benzos also cause more subtle problems:- Why is it so hard to detoxify from benzodiazepines? Not usually aware of mild intoxication Amnesia Physically hard Behaviourally hard We underestimate how much impact it has on the brain… GABA BRAIN CIRCUITRY 60 - 75% OF ALL BRAIN SYNAPSES ARE GABAERGIC Treatment of benzodiazepine dependence Gradual withdrawal –regimen will depend on pattern of dependence and length of dependence – can take years… NO proven role for “substitute prescribing” Possibly use of flumazanil in future to help withdrawal. Small Groups and Feedback Prisoner release planning The doctor won’t prescribe diazepam Continued use “on top” Cocaine and methadone A client smelling of alcohol Please summarise the MAIN concern and give ONE take home message from the group! Some men see things as they are, and say “why?” I dream of things that have never been, and say “why not?” Robert F Kennedy