Dr Sue Pritchard Shipston Medical Centre

 Chronic relapsing condition – similar to others treated in primary care  Mortality 14 x higher for age matched controls  Morbidity: 90% cases of hep C in UK are associated with IVD use

 Effective evidence based treatment with good outcomes  Needs holistic individualised approach – cornerstone of GP care  Good for our communities

 Physical: BBV transmission, complications of injecting including VTE, abscesses, Endocarditis, Poor pregnancy outcomes, Overdose.  Social: Effects on families, criminality, imprisonment, social exclusion  Psychological: Fear of withdrawal, craving, guilt, stigma  Mental health: depression, psychosis, dual diagnosis

 Reduces mortality significantly  Reduced drug related morbidity  Reduces crime  Reduces risk taking behaviour and spread of BBV  Can be done safely without increasing methadone mortality

 RCGP Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care – 2011  Drug misuse and dependence - UK guidelines on clinical management  RCGP Certificate in the Management of Drug Misuse

 NTA describes range of interventions which are intended to remedy an identified drug related problem or condition relating to a person’s physical, psychological and social well being  Structured drug treatment follows assessment and is delivered with a written mutually agreed care plan, which is regularly reviewed

 Political shift towards recovery approach which NTA frames ‘in terms of achieving an individual client’s goals for making positive changes in their lives’.  This is underpinned by more personalised approach to treatment and a balanced system including, even encouraging, abstinence orientated treatment

 A patient’s unique journey  Shared care patients -often stabilised, housed, employed, family  Need opportunity to discuss reduction  ‘ Treatment should end at the point of the patient’s journey which the patient and the prescriber judge to be clinically (not politically or morally) safe and appropriate’

 More than just methadone  Therapeutic alliance ◦ Motivational interviewing – Rollnick and Miller  Engagement – attitudinal approach throughout team  Holistic approach  Family support - ESH  Safeguarding Children  Safety of medicines  DVLA

 New patients seen by SCP/PD  Contact previous GP/CDT team  CDT full assessment with positive swabs and contract  Harm minimisation – Hep C /HIV/Hep B testing, accelerated Hep A /B vaccination schedule.  Overdose prevention advice  Needle exchange scheme at local chemist and needle bin at Ellen Badger Hospital

 Maintenance until stability achieved  Regular health check – aging population! COPD/Hep C/Alcoholic cardiomyopathy  Contraception and STIs  Cascade alerts re contaminated batches  Boundaries – not punitive but consistent  Negotiation re pick ups  Life without drugs – the role of ‘meaningful activity’

 QOF and chronic disease - depression screening questions  Evidence that PHQ9 and GAD score can be used with patients within addiction services.  Improved flexible working with CMHT especially IAPT

 RCGP guidelines:  Treatment reviewed at every contact and needs to be re-examined more formally every 3-4 months to measure improvements in health and wellbeing and to monitor any use of alcohol or drugs and given support to make changes  Toxicology screen frequently at start of treatment and when stabilised two to four times a year.

 Torsades de pointes – ventricular arrhythmia associated with prolonged QTc interval  All those on methadone 100mg or above  Those on methadone + additional factors ◦ Lithium, SSRI, TCA, sotalol, venlafaxine, macrolides ◦ Structural heart disease ◦ Offer ECG – if normal, repeat every 12 months ◦ If abnormal – discuss change in script, reduction in dose, consider cardiology referral

 Therapeutic relationship requires trust and continuity  Continuity of CDT worker and GP  Positive attitude from Primary health care team  Good communication – plans in place, swab results available  Flexibility of CDT worker and GP  Engagement and signposting for other psychosocial issues  Consistency in approach by other GPs in the practice. Annual clinical meeting  Professional peer support