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Opioid Substitution
Treatment in Christchurch
“Of CORS you can do it”
Leadership Day 20 November 2014
Dr Carmen Lowe, Clinical Head, Consultant Psychiatrist and Addiction Specialist
Kaye Johnston Service Manager Speciality and Addiction Services, SMHS
Marc Beecroft, Consumer Advisor
Systems of Care
CDHB VISION
Right Place
Right Time
Right Person
Least restriction
Lowest cost
No waste of patient time
Specialist Mental Health Service
Alignment
Integrated community model
Customer focus
Accessibility
Responsiveness
Capacity building
Effectiveness
Efficiency
Workforce adaptability
Connectedness
Importance of partnership
Model of Care
Consumer centred and family/whanau focussed
Models to build capacity and capability
Efficient & effective utilisation of resources
Principles of Choice and Partnership
Role models to adapt
Work in Progress
Proposal for Change
Review based Steering and Action Groups
Structure of OST services in
Christchurch
Specialist 423 Consumers (24 On Suboxone)
Enter Specialist service AFTER AOD assessment – supported and linked into GP of choice, dose of OST stabilised including dispensing arrangements, case management, psychosocial interventions.
Shared care (GP Authority) 163 consumers
Transition to Shared Care – GP looks after physical health and prescribing, Specialist service continues to monitor review support. Initially reviewed 3 monthly, then annually by Specialist Service.
Pegasus GP Care 139 consumers
Discharged from Specialist Service, assessed as stable long term, transferred to sole GP care with oversight by Pegasus GP Care Committee.
*stats as at 30 June 2014
Demographics Specialist Service
Age range 19-29 years 64
30-44 years 262
45-59 years 245
60+years 15
Gender Male 345
Female 241
Ethnicity NZ European 447
Maori 107
Pacific 11
Other 21
Trends in Demographics
Increasing age of consumers receiving OST
Increasing rates of medical co-morbidities resulting in significant impact on
quality of life, morbidity and mortality
Medical co-morbidities include Chronic Obstructive Lung Disease, cardiac
complications, carcinomas, etc.
High rates of psychiatric disorders
Staffing
15 FTE Case managers – combination of nursing/social workers and 2 AOD counsellors
0.4 FTE Clinical Psychologist
0.45 Psychiatric Registrar
1.7 FTE Medical Officer
1.5 FTE Consultant Psychiatrist (inclusive of clinical head)
Clinical Head – oversees CADS/CORS/Kennedy
0.5 Clinical Manager
0.4 FTE Pukenga Atawhai
Clinical Director, Service Manager and Nurse Consultant– also oversee CADS/Kennedy/Eating Disorders/Mothers and Babies/Anxiety Disorders
*change in Service Manager and Nurse Consultant mid 2014
Name of Service
Not an outcome of the review, but required due to availability of alternative to
methadone
-was confusing for consumers and other services
Now confirmed as:
Christchurch Opioid Recovery Service
Workshop 2013
Development of Service Philosophy
“Our model of care facilitates client centred, recovery and
well-being focused approaches to OST. We are responsive
to the needs of clients, their whanau and our community,
basing our practice of principles of Harm Reduction as
outlines in the New Zealand Practice Guidelines for OST
2014”
Acceptance Criteria
Clients/tangata whai ora will be treated by the service if:
The client/tangata whai ora has a Comprehensive/updated alcohol and drug assessment
Opioids are the main drug of dependence
The client/tangata whai ora has an opioid dependence as defined in DSM-IV or ICD-10
There is physical evidence of current use, e.g. track marks, needle sites, signs of intoxication or
withdrawal, and a positive opioid drug screen OR The client/tangata whai ora has been abstinent in a controlled environment (e.g. prison); or had a brief attempt of abstinence,
The client/tangata whai ora gives informed consent to OST
Where other substance use is present, the client/tangata whai ora are willing to engage in a treatment plan to reduce the risks associated with their use and it is considered they will benefit from OST.
There are no medical contraindications to OST
The client/tangata whai ora has pharmacies that are agreeing to dispense which the service will help facilitate.
Priority admissions/access
Pregnant women.
People with serious co-existing medical and mental health problems.
People arriving in New Zealand already established on OST programmes
overseas.
Clients/tangata whai ora who previously received OST within the last 6
months and who have been unable to maintain stability in the community.
“Clinic” vrs case management model
Traditionally consumers booked into clinic appointment with MO and case
manager, 15 minutes, focus on scripting
Change to 1:1 focus with case manager, and review with medical officer
as clinically indicated.
If clients are not requiring regular review by MO or case manager, then
consumer should be moving through to primary care as per MOH model.
Discharge Criteria - voluntary
The Client/tangata whai ora will be discharged from the service by the clinical team following a planned withdrawal. Ideally this withdrawal is managed in consultation with their Case Manager and Medical Officer to minimise withdrawal symptoms
*if clients wish to re-access OST, they have priority access for a 6 month time period after discharge, and can contact the service directly.
Involuntary withdrawal
Involuntary cessation of OST should be a last resort, and decisions relating to termination of treatment should be initiated only after input from a number of other sources and after all attempts have been made to resolve influencing issues.
The Client/tangata whai ora may be involuntarily withdrawn from the programme and discharged by the clinical team if:
A client’s pattern of frequent overdose or significant intoxication is so uncontrolled that opioid substitutes cannot be dispensed with sufficient safety
A client threatens violence, or is violent towards staff, other clients, a prescriber or a pharmacist and in breach of CDHB zero tolerance to violence.
** A review of the circumstances associated with aggressive behaviour should always precede any decision to withdraw a client from OST).
A client repeatedly displays an inability to keep to the safety
requirements of the OST provider which may include:
-Repeated diversion of medication or loss of doses
-Repeated lack of attendance at appointments
-Repeated refusal to provide observed urine drug screens (or
blood screens) as requested.
The decision to withdraw the client/tangata whai ora from
treatment is made following a formal review of treatment,
consultation with the MDT and in alignment with Section 3.9.2
Involuntary cessation of OST, New Zealand Practice Guidelines
of Opioid Substitution Treatment 2014
Staff education programme/inservice
Focus on developing philosophy, recovery model
Consumer and family engagement and involvement
Challenges
Staff shortages – case managers currently covering multiple caseloads due
to vacancies. Likely to continue until early 2015 when vacancies filled and
new staff orientated.
Lack of whanau room and meeting rooms since other services moved into
workspace post earthquake.
The future
Stream lining consumer pathway into CORS - Assessments undertaken by
CORS – resourcing, staff education and reconfiguration.
Satellite clinics (not occurred since CHCH earthquakes and loss of venue)
Peer support
Consumer input
- Strong consumer team at the table of the Action Group –all with OST
experience
- Treatment perception questionnaire developed – good uptake from the
service
- Stronger consumer feedback mechanisms have been planned and
implemented
- Investigating peer support and further consumer input into the service