MRCPsych addiction psychiatry seminar series Policy, guidance, service structures and legal framework of addiction treatment Epidemiology of addictive disorder Psychological interventions Management of tobacco use and addiction Dr Stuart McLaren March 2010

Policy, guidance, service structures and legal framework

UK drug policy 1998 Tackling drugs to build a better Britain – 10 year strategy 2002, updated 2006 Models of Care for drug misusers 2006 Models of Care for alcohol misusers 2008 Drugs: protecting families and communities – next 10 year strategy

UK Drug Strategy NTORS/effectiveness review/NICE NTA/Healthcare commission NDTMS TOP Harm reduction approach Criminal justice initiatives

Harm reduction approach Defines policies, programmes, services and activities (treatments) that work to reduce the: Health, social and economic harms to: Individuals, communities, and society that are associated with drug use.

Factors associated with harm Route of injection Nature, extent and pattern of use Prevalence of BBVs in IDUs population Life style factors associated with use Drug policy environment Characteristics of healthcare environment

Specific health problems Drug overdose HIV, hepatitis B & C Bacterial infections, including TB Fungal infections Venous and arterial problems Dental problems Respiratory and cardiovascular promblems Mental illness Violence

Harm reductions approaches to injecting drug use Needle (-syringe) exchange programmes Substitute prescribing treatment HIV/AIDS related treatment Hepatitis B vaccination Hepatitis C testing Information, advice and education

NICE guidance 2007 Technology appraisals: -Methadone and buprenorphine for the management of opioid dependence (TAG 114) -Naltrexone for the management of opioid dependence (TAG 115)

NICE guidance 2007 Clinical guidelines -Drug misuse: opioid detoxification -Drug misuse: psychosocial interventions

Department of Health guidelines 2007 Drug misuse and dependence: UK guidelines on clinical management ‘the orange book’

UK commissioning structure National Treatment Agency Drug (A) Action Teams Providers

Structure of treatment services Residential rehabilitation houses Inpatient units Regional drug services Specialist, statutory drug services Shared care/primary care services Non-statutory, street-level services Self -help groups

Structure of treatment services Tier 4residential Tier 3structured community based Tier 2open access (usually non-statutory) Tier 1interface services

Home Office drug initiatives Police custody – drug testing, arrest referral schemes Courts and probation – drug monitoring, RoB, DRRs Prison – CARAT teams Aftercare

Misuse of Drugs Act 1971 and Regulations 2001 Class A – cocaine, ecstasy, heroin, LSD, methadone, Class B drugs injected Class B – amphetamines, barbiturates, codeine Class C – anabolic steroids, minor tranquillisers, cannabis

Misuse of Drugs Act – maximum penalties possession trafficking Class A 7 years + fine life + fine Class B 5 years + fine 14 years + fine Class C 2 years + fine 5 years + fine

Regulations Schedule 1 – no therapeutic value (cannabis,LSD) Schedule 2 & 3 – can be prescribed (heroin, amphetamine, temazepam) Schedule 4 – can be prescribed (mostly benzodiazepines) Schedule 5 – over the counter medications

Implications Doctors can prescribe: Amphetamines Barbiturates Cocaine** Heroin** Methadone ** need HO license to prescribe to ‘addicts’

Mental Health Act 1983 Part I application of Act ‘Nothing… above shall be construed as implying that a person may be dealt with under this Act as suffering from mental disorder….by reason of…dependence on alcohol or drugs’

Mental & behavioural disorders due to psychoactive substance use F1x.4 withdrawal state with delirium F1x.5 psychotic disorder F1x.6 amnesic disorder F1x.7 residual and late-onset psychotic disorder