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Integrated Care for drug users: Principles and practice

Appendix 5 A survey of nhs services for opiate dependents in Scotland - Summary

Introduction

The Department of Health guidelines on clinical management for drug misuse and dependence outline a range of drug treatments and other therapeutic interventions appropriate for treating opiate dependents. These treatments vary in what they set out to achieve, according to what is deemed appropriate for individuals. This study examines the range of treatment options available to opiate users across Scotland and looks at how clinical decisions about treatment are made. The study was conducted by a team from the Health Services Research Unit (Aberdeen University), Ayrshire and Arran NHS Primary Care Trust and the Centre for Drug Misuse Research (Glasgow University).

Aims and Objectives

The main objectives of the study were to investigate:

• the range of options made available in different areas within the Scottish NHS Board areas for treating patients with opiate dependence
• the processes that underlie clinical decision making

Methods

Qualitative interviews were conducted with clinicians working in specialist addiction services across Scotland, Drug Action Team representatives and NHS Board representatives responsible for commissioning of out of area referrals. This report focuses on the findings from the interviews with clinicians. The majority were consultant psychiatrists. An interview schedule was used to conduct the structured interviews. Clinicians were asked about a range of issues including:

Key Findings

• All clinicians reported that methadone was available in their area. 80% were involved in prescribing methadone, the remaining 20% treated clients who were prescribed methadone from another source. Half of clinicians reported that all (or nearly all) their clients were on daily supervised dispensing.
• Almost half of clinicians did not have an 'upper limit' of methadone dose. They reported prescribing at a level required to achieve stability in their clients. The remaining respondents reported an 'upper limit' of between 70-150mgs. Methadone is widely perceived as a long term treatment.
• More than half of clinicians were involved in dihydrocodeine prescribing. The rationale for doing this was not consistent among clinicians.
• Buprenorphine was being prescribed within specialist services in two NHS Board areas. There is interest among clinicians in other NHS Board areas to look at the potential contribution of buprenorphine prescribing in opiate users.
• All clinicians were involved in lofexidine prescribing and almost all clinicians were involved in prescribing naltrexone. Lofexidine and naltrexone were viewed as appropriate for small proportions of specialist addiction services' case loads.
• Almost all clinicians prescribe benzodiazepines. The proportion of patients prescribed benzodiazepines varies greatly among clinicians from less than 5% to over 80%.
• Over half of clinicians identified a sub-group of their caseload (5-33%) who could achieve abstinence relatively quickly. A third thought the majority of their caseload could become abstinent with time.
• Most specialist addiction services offer psychological interventions. A range was identified including relapse prevention, cognitive behavioural therapy, motivational interviewing and anxiety management. Counselling is not always offered and is only mandatory in two settings.
• About one fifth of specialist services offer some form of alternative therapy. Where available, these were provided opportunistically by a staff member in the team trained to provide a specific therapy.
• Approximately three quarters of clinicians identified protocols, often locally developed but based on, or adding to, information in the Department of Health Guidelines on Clinical Management.
• Clinicians reported links between specialist addiction teams and maternity services, mental health services, accident and emergency departments, primary care, social work and criminal justice services. However, the quality of those links, and the extent to which they were formalised, varied.
• The professional make up the addictions team varied between two and six different professions. Teams usually including doctors, nurses and drugs workers. Clinical psychologists, social workers and pharmacists are also commonly represented. Most clinicians were positive about the benefits of multi-disciplinary working. The most common benefit cited was mutual support.
• Fifteen NHS Boards made over 250 'out of area' referrals between April 2000 and March 2001. In some cases these include referrals for people with alcohol problems. In most cases, the clinician responsible for addiction in each area approved these referrals.

Key Conclusions

• Methadone prescribing is almost universally available across Scotland. However, there is some variation in the form that methadone prescribing takes in terms of the dose of prescription and rationale, supervision arrangements and the degree to which it is integrated with counselling services.
• Small amounts of dihydrocodeine prescribing and buprenorphine prescribing are evident. In particular, there is interest among clinicians in looking at the potential contribution of buprenorphine prescribing in opiate users.
• Lofexidine and naltrexone prescribing were widely available, but tended to be for relatively small proportions of clients. This may be a reflection on the small number of patients who were detoxifying.
• The availability of psychological interventions was variable and the use of alternative therapies was not widespread. However, there was interest in developing these.
• Varying degrees of partnership working between and within statutory and non-statutory services were reported. There were examples of good partnership working between agencies, in particular between addiction teams and maternity services.

Key Recommendations

• A co-ordinated and integrated approach to service delivery should be implemented to maximise service effectiveness and minimise service duplication.
• Local service protocols based on the Department of Health Guidelines on clinical management should be developed and regularly reviewed for all drugs prescribed to opiate users.
• There should be greater integration of substitute prescribing and counselling and psychosocial interventions. Further, attention should be given to the role of alternative therapies.

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