Drug Misuse

Sections on the following topics

Case Studies

Pregnancy Guidelines

Pregnancy Cases

Maintenance Guidelines

Supervised Consumption

Case Studies

Either discuss with your group what they would do or discuss the treatment options below. The case develops subsequently…see parts ii-iv. Treatment options have developed since the ‘answers’ were written and there never was a ‘right’ answer. Most are defensible as a response to the given scenario. There is a short ‘case study 2’

Case study 1:

 1. 35 year old man using ½ of 16th oz (0.8g) heroin iv daily. Drug screen +ve to opiates. Second time asking for methadone; previous script only lasted 3 weeks after which he failed to attend for his counselling appointments and was discharged. Has been using heroin for more than 10 years. Asking for a reducing script. Supporting his habit by shoplifting; currently on probation but with new offences due in court soon. He has been seen by a drug counsellor who is asking for a methadone prescription at 50mls with the intention of reducing over about 3-6 months and detoxing.

a. Do you?

i. Advise him to go on methadone maintenance at 50mls.

ii. Start reducing script, reductions to be negotiated by drug counsellor.

iii. Refer for accurate methadone dose assessment and refuse to prescribe methadone until it is carried out.

iv. Start methadone at 30mls and gradually build up the dose over several weeks until stabilised.

v. Rubber stamp the advice from the drugs counsellor (but insist on option iv.) and use the time to address his health problems, especially injecting behaviour (risk of hepatitis B and C), advice about hepatitis C testing (with a view to interferon/ribavirin combined therapy) and giving hepatitis B vaccination. You realise that because of time constraints this will have to be done piece-meal over several consultations for his repeating methadone script.

vi. Do nothing until the local supervised consumption facility is available

Case study 1 – part ii:

8 weeks later he returns for another script. You feel he has stabilised well on the methadone; he has looked much better and says he has stopped shoplifting and using heroin. Unfortunately a recent urine specimen shows opiates as well as the methadone you are prescribing.

b. Do you?

               i. Continue management unchanged and ask about pain killers or cold remedies he may be taking.

               ii. Reduce the methadone at a faster rate.

               iii. Discharge him for 8 weeks (4 weeks?)

               iv. Ask him if he would like to increase the methadone dose or if he would like to continue to try to reduce his heroin use without going for this option at this time.

If the urine had shown opiates and no methadone, methadone dose now 30mls daily.

c. Do you?

               i. Immediately discharge.

               ii. Take witnessed urine and discharge if this shows no methadone.

               iii. Increase the dose of methadone.

Case study 1 – part iii:

Several months later he comes asking for a methadone dose increase. He says that since the dose reached 20mls he has struggled with some withdrawal symptoms, poor sleep and intense craving for opiates. He is angry with himself for starting to use heroin again; although you believe he has been using it all along he has been denying this. His drug counsellor seems unsure what to do. All his urines since commencing his script have shown opiates and methadone.

d. Do you?

               i. Continue with planned detox followed by discharge for 8 weeks (4 weeks?) before recommencing any substitute prescribing.

               ii. Increase his methadone after discussion with his drugs counsellor.

               iii. Prescribe 7 days of Zopiclone to help him over this difficult stage (having informed him that this is a one-off and couldn't be repeated) and agree to hold the methadone dose level for one month after discussion with his drug counsellor.

               iv. Assess him for symptoms of depression and consider using an anti-depressant.

  If the same request was made but his urines had been opiate free for many weeks.

e. Do you?

               i. Continue with planned detox followed by discharge for 8 weeks (4 weeks?) before recommencing any substitute prescribing.

               ii. Increase his methadone after discussion with his drugs counsellor.

               iii. Prescribe 7 days of Zopiclone to help him over this difficult stage (having informed him that this is a one-off and couldn't be repeated) and agree to hold the methadone dose level for one month.

               iv. Assess him for symptoms of depression and consider using an anti-depressant.

Case study 1 – part iv:

Throughout the treatment programme urines have shown amongst the other substances (mainly methadone and opiates) consistent cannabis use.

               Do you?

               i. Discharge him.

               ii. Talk to him about the increased risk of lung cancer.

               iii. Tell him that as far as you are concerned his cannabis use is not a problem. There may be risks to its use but it is not addictive and may help with transferring off other substances, however you do point out that its possession is still illegal.

               iv. As iii but warn him about 'skunk weed'.

Case study 2

2. 45 year old man using heroin iv daily '...as much as I can get...' (even when pushed on quantity patient he seems a little vague). He is also using cannabis, crack-cocaine and benodiazepines but can't really say what the quantities are. He seems intoxicated with drooping eyelids. His appearance is a little unkempt and he smells slightly of alcohol. No urine specimen available. Has been using heroin for well in excess of 10 years and has had several previous methadone scripts which pretty much amount to 'serial maintenance' through various support agencies locally. Asking for a script '...to sort me out until I can get into detox...' Supporting his habit by shoplifting; recently out of prison and currently on probation with new offences due in court soon. He has been seen by a drug counsellor who is asking for a methadone prescription at 50mls to '...stabilise him until I can get him in somewhere...'

Do you?

i. Advise him to go on methadone maintenance at 50mls.

ii. Start reducing script, reductions to be negotiated by drug counsellor.

iii. Refer for accurate methadone dose assessment and refuse to prescribe methadone until it is carried out.

iv. Start methadone at 30mls and gradually build up the dose over several weeks until stabilised.

v. Rubber stamp the advice from the drugs counsellor (but insist on option iv.) and use the time to address his health problems, especially injecting behaviour (risk of hepatitis B and C), advice about hepatitis C testing (with a view to interferon/ribavirin combined therapy) and giving hepatitis B vaccination. You realise that because of time constraints this will have to be done piece-meal over several consultations for his repeating methadone script.

vi. Do nothing until the local supervised consumption facility is available

Guidelines for GP care of mothers using drugs during pregnancy

1^st Draft Sept 2003 – for use now and revision Jan 04:

The drafting of city-wide guidelines for inter-agency working with pregnant drug users is the subject of a steering group. These shorter guidelines specifically relate to the GP’s role and will be updated when the city-wide document becomes available.

We would like to draw attention to a few principles and give some useful information. Please refer also to Drug Misuse and Dependence – Guidelines on Clinical Management (DOH 1999) pp79-83

Referral criteria to higher tier care (Mother and Baby Team at ABC or CDT – see appendix for Mother and Baby Team referral criteria):

Principles for treatment:

Substance misuse care during pregnancy - stability of lifestyle and drug use is the main aim of interventions in pregnancy, although the wishes of the mother should be respected if she wishes to detox. Substitute prescribing of methadone is an important part of achieving stability and should be offered as quickly as possible after assessment highlights the need. During pregnancy it is often observed that motivation is high and progress in addressing drug use is good. Following birth these gains are sometimes maintained but sometimes lost and extra support is appropriate with possibly (depending on the patient’s wishes) a return to pre-pregnancy substitute prescribing doses.

The use of buprenorphine - is currently not recommended in pregnancy due to a lack of data on this application, however mothers already taking buprenorphine probably should not be transferred to methadone unless there are clear reasons to do so

The dose of methadone - should be as much as is necessary to achieve stability of heroin use or its cessation, bearing in mind the wish to minimise the likelihood and severity of Neonatal Abstinence Syndrome (NAS) and the mother’s wishes. Many mothers opt to stabilise on methadone and then reduce the dose in preparation for the birth to reduce the chances of NAS arising. Research evidence does not indicate a clear maternal dose of methadone at delivery which will not cause NAS, however the evidence available and experience seems to indicate that though methadone doses below 15mg are unlikely to result in severe NAS, with doses between 15-30mg there is more uncertainty and when doses are above 30mg a real possibility of NAS remains.

Drug use other than opiates contributes to NAS. We recommend that mothers should receive support in cutting down or stopping (if safe to do so) other drugs especially alcohol, benzodiazepines and nicotine especially during the latter stages of the pregnancy when even stopping smoking for 1 week could make a significant difference. In pregnancy nicotine replacement therapy should be used only if smoking cessation without nicotine replacement fails and liquorice-flavoured nicotine products should be avoided. The patient information for some products contra-indicates their use

Obstetric care - In many cases in conjunction with shared care for her drug use a mother could be having obstetric shared care in the GP setting. Referral for higher tier obstetric care should be based on the existing criteria which apply to all patients. At the same time a referral to a higher tier for her drug use may be made, depending on the criteria above

Partners of pregnant drug users - should also be offered treatment in conjunction with the mother’s care. They should have a treatment plan which is discussed separately and appropriate to their own needs. Mothers tend to be on reduction regimes in pregnancy and this may or may not be appropriate for their partners. If there is some ‘distance’ in the relationship or if it is perceived to be in some way problematic for the mother or the male partner, it may be appropriate for them to be seen at a separate time.

The Orange Book Guidelines suggest a 32 week child protection meeting (not a case conference) and a post natal meeting to plan continuing care. In many cases there will be no need for formal meetings but child protection issues should be the subject of discussions between DSB worker and GP and involve other agencies/involved individuals as appropriate.

A pre-birth planning meeting between prescriber, Drugs Support Worker and others involved within the last 6 weeks of pregnancy resulting in communication with the relevant obstetrician and paediatrician can also be very useful. A suggested communication form is included with these guidelines. It is helpful if the completed form is placed in the substance misuse notes, midwifery/obstetric notes and sent to the paediatrician responsible for neonatal care. It may also be useful to give a copy of this completed form to the patient and (with the patient’s knowledge) to a social worker who knows the patient and if they have been involved during the pregnancy

Multi-disciplinary and inter-agency working - communication is vital in providing good services to pregnant drug users. Particularly important are good relationships with social services and their involvement when specific concerns about a mother’s ability to care for a child exist.

Generally speaking using drugs alone is not sufficient reason for a formal referral to social services but a significantly disturbed lifestyle, particular history (eg previous children taken into care) or particular situations which arise during treatment would make liaison with social workers more likely

Mothers should be informed of circumstances which might result in a referral and told that, should a referral be thought to be necessary, every attempt would be made to inform them prior to the referral being made

Information:

Drs Steve Brinksman and Nigel Modern, Lead GPs with Special Interest (Substance Misuse), Birmingham Primary Care Drug Treatment Team 0121 233 7437/8 Sept 2003

Appendix – Mother and Baby Team Referral Criteria

The Mother & Baby Team works with:

In general the only clients excluded are

The referral criteria are necessarily broad, but in general a client should have two of the following in order to be taken on for case management by the MBT:

Pre-birth planning meeting

(For communicating with midwife, obstetrician and neonatologist + other involved agencies)

Date of meeting:                                            (approx 34 weeks gestation)

Patient’s name:                                                             dob:

Address:                                                                                 Tel:

Current methadone dose:                                       Likely to reduce further?: Y/N

Current street drug use (if none put none):                 

Brief drug use history:

Brief drug treatment history:

History of substance misuse care in this pregnancy:

Age(s) of any existing children:

Expected date of delivery:                                                        Midwife:                                                                                

Hospital where delivery is booked:                                             Tel:

Obstetrician:                                                 Paediatrician (neonatal care):

Prescriber (if GP leave blank):                                               Drug worker:

Tel:                                                                                         Tel:

GP:                                          Tel:                                         Social services contact:

Surgery:                                                                                 Tel:                                        

Other contact (Health visitor/community midwife):

Tel:

Birmingham Primary Care Drug Action Team Sept 2003

Pregnancy Case Studies

Training 19^th Feb 2004

Case study 1

A 25 year old patient you’ve never met before but who has been on your list for several years presents at 18 weeks pregnant (first pregnancy) and tells you that she has been using heroin (inhaled) for the last 5 years, recently about 0.75g daily. She is asking for help to detox from heroin although you feel that her chances of successful detox given her current lifestyle is not high. She has never requested treatment for this before from the surgery and as far as you know has never had treatment in secondary care. She has been shoplifting to support her habit and has court appearances coming up but no previous convictions. Heroin is her primary drug but she occasionally buys benzodiazepines and uses crack about once a week.

Case study 2

A 32 year old patient of yours is pregnant for the second time. She is well known to you and is currently stabilised (though still using some street heroin) on 50mls methadone and seeing the DSB worker regularly, although you haven’t seen her until now for 8 weeks. She has made good progress and though still on probation she has no outstanding court cases. You know the family well (including the extended family) and are aware of social services involvement owing to some concerns about her daughter, although the 3 year old is not on the Child Protection Register. Her partner is also known to you but is not currently to your knowledge in treatment.

The Structuring of Interventions for Maintenance     1^st Draft Sept 2003 – for use now and revision Jan 04:

It is widely recognised that although successful maintenance using substitute prescribing is one of the best options in facilitating long-term change for an opiate addicted person, there is a need to give structure to the process. Many choose to do this through regular Care Plan Review.

Research has highlighted the need to address the common problem of a concurrent addiction to alcohol and experience indicates commonly the importance of other issues such as housing needs, debt and employment issues as well as some people’s need for specific specialist interventions eg therapies such as cognitive behaviour therapy, counselling or work with the social network of the drug user.

‘…Successful ongoing maintenance…’ – a definition (if anyone knows of a widely accepted one please let me know)

Stability of lifestyle achieved by the use of a substitute opioid which gives an individual the option to separate themselves from a drug using lifestyle and to begin building an alternative

Markers of stability:

Care Plan Review:

The regular revision of an individual’s Care Plan is an important part of maintenance therapy and normally occurs at 3 or 6 month intervals following liaison with the patient and other parties to the 4-Way Agreement.

The aim of the Care Plan is to highlight current priorities for change and actions to be undertaken to achieve this change, which should be very specific eg ‘…attend Job Centre for back-to-work advice…’, ‘…attend advice centre for debt counselling and planning to schedule debt…’, ‘…attend course of CBT…’, ‘…attend _______Day Care Project…’

At different stages, different types of need will present and it is helpful to think along the lines of addressing ‘common’ needs first (eg housing issues, resolving legal issues and stopping re-offending, debt issues or brief intervention for an alcohol problem) and more complex need (eg relationship issues, social network interventions, a refractory alcohol problem, trauma or abuse issues and a revealed need for psychotherapeutic interventions or counselling) later. Clearly if a person fails to move on after or fails to engage in ‘common’ interventions then the reasons may lie in more complex needs.

Generally speaking the therapist skills necessary to address ‘common’ needs will reside in Primary Care and those for more complex needs in Secondary Care.

Drs Steve Brinksman and Nigel Modern, Lead GPs with Special Interest (Substance Misuse), Birmingham Primary Care Drug Treatment Team 0121 233 7437/8 Sept 2003

The role of supervised consumption in early maintenance treatment:

‘…successful ongoing maintenance…’ – a definition

Stability of lifestyle achieved by the use of a substitute opioid in combination with psycho-social support, which gives an individual the option to separate themselves from a drug using lifestyle and to begin building an alternative

Markers of stability:

Successful ongoing maintenance will probably be characterised by –

Drs Steve Brinksman and Nigel Modern, Lead GPs with Special Interest (Substance Misuse), Birmingham Drug Action Team (Primary Care) 0121 233 7437/8 Jan 2004