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 societythat 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:AmphetaminesBarbituratesCocaine**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