Good Good Prescribing Prescribing to support Criminal Justice to support Criminal Justice

InterventionsInterventionsLucy CockayneLucy CockayneConsultant Psychiatrist Consultant Psychiatrist

Lead ClinicianLead ClinicianNHS Fife Addiction ServiceNHS Fife Addiction Service

Structure of the sessionStructure of the session

Introduction (5 minutes)Introduction (5 minutes) Overview of prescribing principles (20 minutes)Overview of prescribing principles (20 minutes) Small group scenarios (10 minutes)Small group scenarios (10 minutes)

Prisoner release planningPrisoner release planning The doctor won’t prescribe diazepamThe doctor won’t prescribe diazepam Continued use “on top”Continued use “on top” Cocaine and methadoneCocaine and methadone A client smelling of alcoholA client smelling of alcohol

Feedback (5 minutes)Feedback (5 minutes)

Introduction –Introduction –What are the main issues?What are the main issues?

Are there Common Principles to non forensic Are there Common Principles to non forensic treatment?treatment? Write down your top 3Write down your top 3

Are there differences in practice? Are there differences in practice? Write down 3 differencesWrite down 3 differences

Why do these occur? Are these good Why do these occur? Are these good differences or not?differences or not? Group discussionGroup discussion

What are the aims of good What are the aims of good prescribing in a forensic setting?prescribing in a forensic setting?

Alleviate sufferingAlleviate suffering Reduce harm associated with drug useReduce harm associated with drug use Reduce criminal behaviourReduce criminal behaviour Reduce complications of drug misuseReduce complications of drug misuse

Reduce risk of BBV transmissionReduce risk of BBV transmission Complications of injectingComplications of injecting General healthGeneral health

Promote recoveryPromote recovery

Specific Challenges Specific Challenges 1. For Prison Prescribing1. For Prison Prescribing

Continuity of prescription Continuity of prescription from the communityfrom the community Back into the communityBack into the community

Especially for short termersEspecially for short termers

Volume of potential clients and their speed of Volume of potential clients and their speed of movement through the systemmovement through the system Tension of depth vs speed of assessmentTension of depth vs speed of assessment

Response to drug related death dataResponse to drug related death data Issues around loss of toleranceIssues around loss of tolerance

Cost and staffingCost and staffing

2. Community criminal justice 2. Community criminal justice prescribingprescribing

Tensions within the teamTensions within the team Differing opinionsDiffering opinions Expectations from courtExpectations from court Treatment as more than a prescription!Treatment as more than a prescription!

““First do no harm”First do no harm” ““More than methadone”More than methadone”

What forms of drug misuse have What forms of drug misuse have evidence based prescribing options?evidence based prescribing options?

OpiatesOpiates MethadoneMethadone BuprenorphineBuprenorphine

Benzodiazepines?Benzodiazepines? Actually no licensed prescribing- controversy over Actually no licensed prescribing- controversy over

structured detoxificationstructured detoxification AlcoholAlcohol

DetoxificationDetoxification Acamprosate, naltrexone and antabuse as adjunct to Acamprosate, naltrexone and antabuse as adjunct to

abstinenceabstinence

Alcohol TreatmentsAlcohol Treatments

DetoxificationDetoxification Chlordiazepoxide (Librium)Chlordiazepoxide (Librium) Vitamin supplementationVitamin supplementation

Aids to maintaining abstinence or controlled Aids to maintaining abstinence or controlled drinkingdrinking Antabuse (abstinence only)Antabuse (abstinence only) AcamprosateAcamprosate NaltrexoneNaltrexone

Treatments exist:- Average alcohol Treatments exist:- Average alcohol intake (drinks / week, TLFB) –but intake (drinks / week, TLFB) –but

they’re not a “cure”they’re not a “cure”

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Opiate dependenceOpiate dependence

Four treatment types:Four treatment types: AgonistAgonist eg methadoneeg methadone AntagonistAntagonist eg naltrexoneeg naltrexone Partial agonist eg buprenorphinePartial agonist eg buprenorphine SymptomaticSymptomatic eg lofexidineeg lofexidine

Think lightbulbs! 100w vs 60w vs dead!Think lightbulbs! 100w vs 60w vs dead!

Lightbulbs…Lightbulbs…

Heroin Methadone

x x

x

x

Buprenorphine (Subutex, Suboxone)

Naltrexone

Agonists

Partial agonist

Antagonist (Blocker)

WHY NOT JUST METHADONE?WHY NOT JUST METHADONE?

““If the only tool you own is a hammer, everything If the only tool you own is a hammer, everything starts to look like a nail”starts to look like a nail”

Choice increases retention in treatmentChoice increases retention in treatment Choice increases patient “buy in”Choice increases patient “buy in” Different patients need different treatmentDifferent patients need different treatment

Some want sedative effectsSome want sedative effects Some need to be clear mindedSome need to be clear minded Some are at higher risk of overdoseSome are at higher risk of overdose Some need to avoid drug interaction or side effectsSome need to avoid drug interaction or side effects

Prescribing for complications of Prescribing for complications of substance misusesubstance misuse

Important to help progress through treatment and Important to help progress through treatment and prevent relapseprevent relapse

Up to 40% have mental health needs that may Up to 40% have mental health needs that may benefit from prescribingbenefit from prescribing

Physical health problems commonPhysical health problems common

Current barriers to good quality Current barriers to good quality treatment in forensic settingstreatment in forensic settings

1. Organisation factors1. Organisation factors

StigmaStigma

Unrealistic expectations and false beliefs…Unrealistic expectations and false beliefs…

Confusion between getting addicted and treating Confusion between getting addicted and treating addiction and its consequences –ie cause and effectaddiction and its consequences –ie cause and effect

Lack of flexibilityLack of flexibility

2. Patient factors in prescribing2. Patient factors in prescribing

““Motivation”?Motivation”?

ComplianceCompliance

Severe dependenceSevere dependence

Complex issuesComplex issues

Memory problemsMemory problems

There is no single, one There is no single, one “best” treatment for ever “best” treatment for ever

and everand ever

the best treatment is the the best treatment is the one that suits the client at one that suits the client at

that timethat time

Where does medication fit in the Where does medication fit in the treatment programme?treatment programme?

House theory of addiction House theory of addiction medication fills in the foundations.medication fills in the foundations. Foundations come firstFoundations come first Foundations are only the start…Foundations are only the start… Foundations must be strongFoundations must be strong Changes in foundations may have Changes in foundations may have

catastrophic effects.catastrophic effects.

““Drug addiction is a chronic, Drug addiction is a chronic, relapsing brain disease”relapsing brain disease”

Benzos also cause more subtle problems:-Benzos also cause more subtle problems:-

Why is it so hard to detoxify from Why is it so hard to detoxify from benzodiazepines?benzodiazepines?

Not usually aware of mild intoxicationNot usually aware of mild intoxication AmnesiaAmnesia Physically hardPhysically hard Behaviourally hardBehaviourally hard We underestimate how much impact it has on We underestimate how much impact it has on

the brain…the brain…

GABA BRAIN CIRCUITRYGABA BRAIN CIRCUITRY

60 - 75% OF ALL BRAIN SYNAPSES ARE GABAERGIC

Treatment of benzodiazepine Treatment of benzodiazepine dependencedependence

Gradual withdrawal –regimen will depend on Gradual withdrawal –regimen will depend on pattern of dependence and length of pattern of dependence and length of dependence – can take years…dependence – can take years…

NO proven role for “substitute prescribing”NO proven role for “substitute prescribing” Possibly use of flumazanil in future to help Possibly use of flumazanil in future to help

withdrawal.withdrawal.

Small Groups and FeedbackSmall Groups and Feedback

Prisoner release planningPrisoner release planning The doctor won’t prescribe diazepamThe doctor won’t prescribe diazepam Continued use “on top”Continued use “on top” Cocaine and methadoneCocaine and methadone A client smelling of alcoholA client smelling of alcohol

Please summarise the MAIN concern and givePlease summarise the MAIN concern and give

ONE take home message from the group!ONE take home message from the group!

Some men Some men see things as see things as they are, and they are, and say “why?”say “why?”

I dream of I dream of things that things that have never have never been, and been, and say “why say “why

not?”not?”

Robert F KennedyRobert F Kennedy