Certificate in the Management of Substance Misuse Part 2

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• Certificate in the Management of Substance Misuse
  - Part 2

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Welcome to RCGP 2

• Since 2001 1676 candidates from all over the
  country have successfully passed the Certificate
  part 2
• Workforce standard (NTA and Healthcare
  Commission)
• Specific reference to this course in CGs, DH PwSI
  frameworks and RCGP/RCPych Joint Council report -
  Roles and responsibilities of doctors working
  with drug users

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More treatment, better treatment safer treatment

• The numbers in drug treatment in England have
  more than doubled 85,000 in 98/99 to 202,000 in
  07/08 (up by 138)
• Retention in drug treatment has improved 78 of
  new starters retained at 12 weeks
• Successful treatment completions up (51 of all
  those discharged in 07/08
• Waiting times three weeks or less (down from 9
  weeks in 2001)
• DIP and IDTS offers end to end treatment for
  offenders

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Since 2006 - IDTS

• Strengthening existing links between CARATS,
  prison health care and throughcare teams in the
  community requires a move toward a more
  integrated drug treatment system.
• Implementing DH clinical guidelines (2006) for
  the management of drug dependence in the secure
  environment

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What does the evidence tell us?

• Drug treatment can help the substance misusers
  achieve some good outcomes
• Reduce drug use
• Reduce crime
• Improve health
• Protect against blood borne viruses
• But. drug treatment alone can only go so far

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What has been commissioned ?

• Drug Treatment Systems
• Models of Care 2002 updated in 2006
• Treatment tiers
• Tight definitions of drug treatment focussed on
  clinical interventions
• Evidence based pathway for heroin misuse
• Evidence based pathway for crack misuse
• Pathways for prison treatment ( heroin and crack)
• Community treatment for cannabis, cocaine, and
  other types of drug misuse

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Models of Care (2002) Updated 2006
Reintegration

Clinical Treatment
TIER 1
TIER 1
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What have we been delivering?

• Substance misuse treatment often delivered in
  isolation from family and local communities
• Fails to encourage service users into employment
  and training
• Fail to build in access to wider networks of
  rehabilitation and recovery

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Treatment mismatch?

• United Nations and World Health Organisation
  (2007) definition of drug misuse . a
  multi-factoral health disorder that often follows
  the course of a relapsing and remitting chronic
  disorder.

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Challenge

• to deliver multidisciplinary integrated pathways
  of drug treatment and social reintegration
• to demonstrate greater integration and seamless
  interface with mainstream
• to build capacity within communities e.g.
  community support networks and mutual aid

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The importance of social capital

• The extent to which an individual has the
  necessary personal and financial resources upon
  which to build a new life
• Criminal record
• Debt
• Lack of education
• Poor employment history
• Homeless
• Disconnected from

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HMG 2008 - New Drugs Strategy

• Greater focus on reintegration
• enabling drug misusers to gain education and
  employment
• Focus on the family and on communities affected
  by substance misuse
• Emphasis on the needs of children of substance
  misusing parents
• Debate about what constitutes recovery

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The Recovery Debate

• We should not be distracted by the siren voices
  telling us that abstinence-based treatment is the
  only way forward. That is not evidence-based, and
  when it was tried in the 1970s and 1980s it did
  not work
• On the other hand, neither should we deny people
  the opportunity for recovery by focusing solely
  on maintenance. People go into treatment wanting
  to come out, having overcome their dependency.
  Maintaining a balance of treatment options across
  the spectrum is essential, and we need to have
  the confidence to keep espousing the middle way.
• Paul Hayes NTA June 2007

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• The process of recovery is characterised by
  voluntarily sustained control over substance use
  which maximises health and well-being and
  participation in the rights, roles and
  responsibilities of society.
• UK Drug Policy Commission
• NTA conference 2007

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Must dos should dos and benchmarks
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Must dos for drug treatment commissioned by the
NHS

• NICE technology appraisals (TAs)
• Commissioners are required to fund and resource
  medicines and treatment recommended
• Usually within three months of NICE issuing the
  appraisal
• Examples NICE TA 114 Methadone and Buprenorphine
  for the Management of Opioid Dependence, NICE TA
  115 Naltrexone for the Management of Opioid
  Dependence

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Should dos

• NICE Clinical Guidelines
• Commissioners and providers are expected to
  review the current management of clinical
  conditions and consider the resources and time
  needed to implement the guideline.
• E.g. Drug Misuse Psychosocial Interventions,
  NICE clinical guideline 51 and Drug Misuse
  Opioid Detoxification, NICE guideline 52

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Should dos (2)

• NICE public health intervention guidance -
  Services are expected to review current practice
  and consider the resources and time needed to
  implement the guideline
• E.g. Community-based Interventions to Reduce
  Substance Misuse Among Vulnerable and
  Disadvantaged Children and Young People, NICE
  public health intervention guidance 4,
  forthcoming guidance on needle exchange and
  alcohol misuse and dependency

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Drug Misuse and Dependence Guidelines ( 0range
book 2007)

• Reflect the NICE guidelines and the
  NICE-recommended interventions
• Other aspects of guidance used as benchmark by
  regulatory and inspectorate bodies e.g. GMC and
  HCC
• Services funded by public money expected to act
  in line with the guidelines (this expectation is
  built into national policy, and inspectorate and
  regulatory frameworks)

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Certificate 2 - 2009 cohort

• Provides background knowledge and opportunity to
  familiarise and interrogate the evidence behind
  the must dos and should dos
• Provides an environment to discuss and understand
  how to deal with the 90 rule
• Develops skills in clinical governance and risk
  management
• Highlights key responsibilities for prescribers

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Course objectives

• Assess understanding of and core competence in -
• Harm minimisation and overdose prevention
• Clinical assessment
• Care planning and review (keyworking)
• Core formal psychosocial interventions for drug
  misuse ( including dual diagnosis)
• Pharmacological interventions
• Testing and vaccination against BBV
• Treatment of Hep C

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Delivering effective treatment

• OPTIMISE treatment to maximise benefit
  (psychosocial, pharmacology, monitoring)
• Standard intensity community pathway

Discrete psychosocial for drug misuse
Psychosocial for depression
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• Opioid detoxification pathway and aftercare
• - for opioid users committed to immediate
  abstinence and who have sufficient community
  support

Care plan
Review
Assessment Keyworking
Psychosocial support

Stabilisation and then detoxification
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• Low intensity community pathway
• e.g. relatively short drug misuse, low
  complexity, non opioid drug misusers

Care plan
Review
Assessment Brief
intervention
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Special populations

• Dually diagnosed/Mental health
• treat anxiety and depression in drug services
• treat SMI with MH services
• Young people - different interventions and
  therefore competencies
• Older drug misusers - increasing health
  needs/management of long term conditions
• Drugs users in pain need the same - or more -
  medication

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Special populations the secure environment

• The secure environment presents a tension between
  the rights of the patient and the rights of the
  prisoner
• Limited access to patients, but high level of
  professional accountability
• Complex needs the norm
• Regular and sometimes unplanned transfer of
  patients

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During the course watch out for ..

• New guidance for reducing unplanned discharge
• New guidance for injectable opioid prescribing
• Naloxone pilots
• Training and employment pathways for drug
  misusers interface with Job Centre plus
• New courses from the RCGP introductory
  certificate in alcohol misuse, certificate in the
  management of the younger misusers and BBV

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And discuss in your groups the hot topics

• TOPS
• Contingency management
• Personal health budgets
• Safeguarding children (implications of review of
  Baby P)
• The future of shared care
• Abstinence vs. maintenance

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RCGP Substance Misuse Unit

• lharris_at_rcgp.org.uk
• Linda.harris2_at_wdpct.nhs.uk