1 Kennedy Roberts Senior Medical Officer and Clinical Lead North Cluster Glasgow Addiction Services Community Addiction Teams What are the challenges for drug prescribing services? Scottish Drugs Forum 28th Feb 2007

2 What are the challenges for the service user? Accessibility Engagement Retention in treatment Effective outcome for service user and clinician subjectively as well as objectively

Royal College of General Practitioners (Scotland)

8 Not so Surprising News! For many current IDVU’s there are multiple contraindications to therapy.

9 Clinical Guidelines on the management of Hepatitis C Booth et al GUT 2001 Some patients on oral methadone and particularly those individuals who are committed to rehabilitation programmes may be considered for treatment

10 Clinical Guidelines on the management of Hepatitis C Booth et al GUT 2001 Or is that MAYBE?

11 Surprising News! Studies have shown that IDU’s current, former and relapsing do just as well in treatment for HCV as non users. This is in terms of: Retention in treatment. Clearance of the virus. (Also low rates of subsequent reinfection)

12 Here are some of them! Backmund M, Meyer K et al Hepatology 2001 Cournot M, Gilbert A, et al Gastroenterology Clin Biol 2004 Dalgard O, Bjoro K, et al Eur Addict Res 2002 ( 5 years follow up )

13 Here are some more of them! Interferon alpha therapy for hepatitis C: Treatment completion and response rates among patients with substance use disorders. Substance Abuse treatment, Prevention and Policy ( U.S.) Published 12/01/2007

14 There are no drug services currently integrated with hepatology/gastroenterology clinics. But we have some managed clinical networks We do have plans to look at this: Hepatitis C Action Plan for Scotland_ The Testing, Treatment Care and Support Working Group are well aware of the changing view of treating IDU infected with HCV- Needs Assessment is being carried out

15 Coal face Issues Service users may be using for 1 to 4 years before presentation: Issues for education ( Probably need to start at the primary school) Issues for NDX Issues for outreach.

16 Coal face Issues Alcohol primary and secondary Co-morbidity.

17 Coal face Issues Where are the rest of the 50,000? Who is best placed to: identify? engage? test? treat- managed clinical network

18 Case Study 1 Female patient born Jan 1971 Fairly typical history of drug misuse starting early teens Little alcohol involved initially mainly cannabis, “recreational” drugs, benzodiazepines and opioids 1 st IV use aged 18 Various interventions from 22 when first attended specialist service. First substantial period of abstinence from 25 years to 28 years of age on methadone prescription

19 Case Study 1 28 years of age alcohol “social drinking” pubs only 31 problematic drinking at home usually vodka. Average consumption 1 litre / day vodka. 32 required “eye opener” 33 ( Jan 2004) first alcohol detox. Residential ( suspicion of previous convulsion related to benzodiazepine/alcohol withdrawal) Rapid relapse to alcohol, became jaundiced, admitted medical ward( May 2004), presence of alcoholic liver disease and oesophageal varices noted.HCV diagnosed.

20 Case Study 1 May to Nov 2004 continued illicit drug free but return to alcohol.Approxiamtely half to whole bottle vodka daily. Methadone reduced to 55mgs daily by this time. 19 th November 2004 re-referred to medical clinic deeply jaundiced. Diagnosis alcohol related cirrhosis. 26 th Nov 2004 died.

21 Case Study 2 Female patient born 1972 Problematic alcohol use at 12 years of age Daily alcohol use to intoxication several days a week at 14 years Alcohol dependency 16 years use of benzodiazepines and buprenorphine 18 First IV use of buprenorphine 19 First IV use of heroin

22 Case Study 2 Female patient born reasonable period of abstinence on methadone 28 to 33 unstable, in and out of methadone treatment 33 Returned to full engagement with services, methadone dose max. 110 mgs currently on 80 mgs Past 2 years alcohol more and more of a problem This year in patient alcohol detox. Relapsed and currently waiting for urgent reassessment ( to-morrow) With view to further detox.

23 Case Study 2 Female patient born 1972 Recent admission to medical ward. GI bleed.(still awaiting more results) HCV diagnosed PCR positive. Liver function tests disturbed alcohol/HCV Management! Prognosis?