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