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 4 residential

• Tier 3 structured community based

• Tier 2 open access (usually non-statutory)

• Tier 1 interface 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