Prescribing for young people

• What the literature has to say

• hype’s prescribing process

• hype young people’s experience

Prescribing for young people

• Evidence• Criteria• Consent and competency• Aims of treatment• Principles of good practice• Prescribing• Assessment

Community Detox Service

Information for referrers

The above service was started in January 2003 for young people aged up to 18who were looking for a rapid withdrawal with a view to abstinence.

Referrals Criteria• Young people who have expressed a desire for a rapid detox from opiates. • Young people on 30mg or less of methadone.

Exclusions• Medical or psychiatric history that would indicate community detox as a risk to physical or mental health. • Young people with a history of drug induced psychosis. • Young people with a current active alcohol dependence. • Young people with a history of violent or abusive behaviour towards staff.

Referrals ProcessGPs: Referrals should be made in the usual way. It would be helpful if the referral letter was headed as a “Referral for Detox”. Agencies: Pleasecomplete the hype Community Detox Service Referral Form and either fax or mail it to us. Copies can be obtained from hype if you don’t alreadyhave one.

Detox assessmentWe aim to offer appointments within a week of receipt of referral by the Detox Service. The Detox Assessment process would normally take 2-4appointments over two weeks to complete. This will focus on exploring motivation for change, physical and mental fitness and the social supportsavailable to the young person. There will also be an exploration of previous detox experiences and the reasons behind relapses. This will help theyoung person to use these experiences as useful learning tools in identifying areas of vulnerability to relapse and promote self-awareness in relationto their addiction recovery.

PreparationFrom the information gathered at the assessment stage, ways in which to best support the detox process will be identified with the patient. Thisprocess will include palliative care to minimise physical withdrawals, ways in which to self-monitor and looking at identifying relapse cues andtriggers.

Strategies for cues and trigger avoidance will be discussed. The emphasis will be on the young person taking responsibilityfor the detox by way of exercises designed to promote cognitive restructuring and self-awareness. Practicalities such asmedication regimes and appointments will also be organised at this time. Supporting relatives or others will have theopportunity to be included at this stage, with the young person’s consent, for advice and support regarding their role in thedetox.

DetoxThe detox method will be identified with the young person at the detox assessment stage and although medication regimesmay differ, the level of psychosocial support is the same. The young person will be seen daily for the first two weeks(excluding Saturday and Sunday). Advice and support will be offered throughout on the management and monitoring ofwithdrawal symptoms, as well as continued focus on relapse prevention. The young person will be encouraged to refer tothe strategies identified in the assessment and planning stages to help with cravings and cue/trigger avoidance. Theeffectiveness of these will be monitored. Staff will liaise with relevant medical colleagues regarding any adjustments tomedication regimes and random urine testing will be carried out to monitor detox authenticity.

Relapse preventionThe young person will be offered the opportunity to commence opiate blocking medication to protect their abstinence. Theconsumption of this medication should be supervised by a supportive other and in order for this to begin, the young personmust remain opiate free for a minimum of seven days. In addition, the young person will be offered time limited individualrelapse prevention sessions. This will be for ten sessions, one per week, each focusing on a particular aspect and addressingdifficulties as they arise.

Follow Up/ aftercareMany young people wish to cut their link with drug services following detox or relapse prevention and as part of thedischarge process the need for ongoing support will be assessed on an individual basis. Referral either back to anotherworker within hype or to other agencies will be made with the young person’s consent. Those who do not wish any furthersupport will at this point be discharged from the service.

All enquiries are welcome and should be made to:Jayne ReedSenior Community Mental Health Nurse Tel: 0131 466 4607Hype Fax: 0131 466 4604

Referral Form

Date _________________ Referrer __________________

Name _________________ Address __________________

DOB _________________ GP ______________________

Drugs Used: Include Alcohol _____________________________________

Current Pattern of Use ___________________________________________

Drug Use History

Age Drug Amount Frequency Route Still Using

History of Mental Health

Age Problem Diagnosis Treatment Where Outcome Ongoing?

History of Medical Problems

Age Problem Diagnosis Treatment where Outcome Ongoing?

Community Detox Service

Social Situation/Environment

Current accommodation ______________________________

Accommodation problems ____________________________

Proximity to drug using circle _________________________

Current education/work status _________________________

Non drug using supportive/significant others

Name Relationship Length known Addictions? Support detox?

History of previous detoxes

Age Where Method Outcome Days drug free Relapse trigger

Motivating factors in previous detoxes

1 2 3

Motivating factors for this detox

1 2 3

Any other relevant information

Community Detox Service

Self-Assessment (please complete and bring to appointment)

Name__________________________________

How long have you been drug dependent? __________________________________

Have you ever detoxed before? Yes/No (if no, go to page 3

How many detox attempts?_____________________________________________

When were these? (give month and year) __________________________________

Why did you choose to detox on these occasions? ___________________________

Where did you detox? _________________________________________________

Did you take any medication to help with detoxing? _________________________

Please state what:_____________________________________________________

How long did your detox (es) last? ________________________________________

Did you become opiate free? _____________________________________________

What is the longest you have been free of drugs?_____________________________

Who or what were supporting you through detox/abstinence?___________________

What have you learned about your addiction from your previous detox/ abstinence experiences? _________________________

RelapseWhat led to your relapse(s)? Please circle all that apply.

Cravings Depression Feeling stressed Life pressuresBoredom Lack of support Anxiety Family relationshipsFeeling isolated Prison Couldn’t tolerate withdrawalsBeing offered drugs Realise didn’t want to stopDidn’t know how to cope drug free Other (please state)

Previous withdrawal experienceWhat withdrawal symptoms have you had before? ____________________Was there any symptom you found too difficult to cope with? ___________

This detoxWhy do you want to consider opiate detox now? _____________________Are you taking any other drugs (including cannabis or alcohol)? Yes/NoIf yes, what and how much do you take every day? ___________________Are they prescribed? Yes/No. If yes, who prescribes? ______________Are there any other drugs including cannabis and alcohol that you could not do without? Yes/No. If yes, what? _____________________________Will you continue to take other drugs during your detox? Yes/NoIf yes, what? _______________________________________________Do you want to be opiate free by a particular date? Yes/No. If yes, when and why?

Social CircumstancesDo you have children? Yes/No. If yes, Name Age Gender Main carerDo you have anyone living with you who depend on you to look after him or her? Yes/No. If yes, statewho and your relationship ________ __________________________________________________

Community Detox Service

Substance Use Diary

Name ______________ Week Beginning _______________________

Day What & How much Where, when & Why did you use?

did you take who with Physical Emotional

Vital Sign & Opiate Withdrawals Monitor

Name ___________________________________

DateTime

SignsInsomniaSweatingHot/ColdYawningDiarrhoeaRhinorrhoeaSedationElationVomitingAnorexiaPilo-erectionDrug seekingRestlessAgitationLacrimation

ObservationsBlood Pressure MmHgPulse BPMPupil Size

Assessed by __________________________________________________________Scores 0 – absent 1 – not sure 2 – mild 3 –moderate 4 - serve

Prescribing Service

Community Detox Service

Decisional Balance

Name ____________________________

What was/is good about current What was/is bad aboutdrug use? Current drug use?

What would be good about not What would you miss Using opiates? About opiates?

Community Detox Service

Home Environment Assessment

Name: ____________________________

Availability of supporter Attitude of supporterAlways available 0 Very supportive 0Often available 1 Supportive 1Sometimes available 2 Slightly supportive 2Never available 3 Not supportive 3

Commitment of supporter Level of noiseVery committee d 0Tranquil 0Committed 1 Reasonably quiet 1Slightly committed 2 Noisy 2Not committed 3 Very noisy 3

Space to be alone Presence of young children/petsAmple room 0 Nochildren or pets 0 Some room 1 Sometimes present 1 Little room2 Always present 2None 3 Presence is disruptive3

General Atmosphere Presence of other substance usersVery organised 0 Never present0Organised 1 Sometimes present 1Slightly disorganised 2 Often present 2Disorganised 3 Always present 3

Areas for Care Planning Score______________

Treatment Aims

Name ________________________

Treatment Aim Review Date

Young Person DateNurse Date

Prescribing Service

Suitability Assessment

Young person’s name_________________________Date of birth __________________Self Assessment completed and returned? Yes/NoDecisional Balance completed and returned? Yes/NoSubstance Use Diary completed and returned? Yes/NoDoes the young person wish to consider lofexadine? Yes/NoBaseline pulse: _________bpm BP.: __________mmHgDate and results of last urine screen:_____________________________HealthIs there any physical/mental health history?Physical:Mental:Medical ResponsibilityWho is prescribing for detox? Date prescription written Date GP informed

Community Detox Service

Contract for Community Detox

Name_________________For opiate Community Detoxification to take place safely, there are certainconditions, which we expect you to follow. 1. You agree that the responsibility for any medication prescribed is yours. 2. You agree not to take opiate drugs (except those, which you are legitimatelyprescribed,) throughout the detoxification process. 3. You agree to be randomly tested for drugs. 4.You agree not to be physically or verbally abusive to staff. 5. You agree to attend all arranged appointments.

Failure to comply with any of the above may lead to your community detoxbeing stopped.

Please sign here to show that you fully understand and are in agreement with thisconsent form.

Young Person_________________________ Date_________Nurse______________________________ Date_________

Community Detox Service

Date________Dear Dr_________

Re opiate detox for name dob address .

I am writing to let you know that ____________ has completed their detox fromopiates. I will continue to see them for ten weeks relapse prevention. I will writeand inform you of their progress following this piece of work.

As you have previously agreed to prescribe Naltrexone for _____________, pleasearrange for a prescription of Nalorex, __mg daily to be available for collectionfrom your surgery on ________.

Yours Sincerely

Jayne ReedSenior Community Mental Health Nurse

Community Detox Service

Certificate of Achievementis hereby granted to:

…………………..to certify that you have tested negative for opiates

Well Done!Granted: (date)

Jayne Reed, Senior Community Mental Health Nurse

Prescribing review

• Why were you referred to hype?• Why did you need a prescription?• What are you prescribed?• How has your prescription helped you?• Are there any negative effects of receiving a

prescription?• How would your life be different if you hadn’t

received a prescription?• Is there anything that could have been done

differently?

Why were you referred to hype?• “Because I was using opiates (smack)”• “I had a bad heroin problem at a very young age”• “I just wanted to come off and the doctor told me to come

to hype for help because hype specialises in this help”• “I referred myself cause I wanted to get off heroin as it

was no life”• “Spoke to my social worker about being on kit. Told him I

had been before for hash. He organised a meeting”• “My mum’s support worker thought it might be good for

me. That was the first time I really spoke about my drug problem”

Why did you need a prescription?

• “Because I had a habit. I wanted to come off. It’s hard though, it’s really addictive”

• “Cause I wasn’t strong enough to do it on my own. I tried to go cold turkey with my mum and dad but it didn’t work”

• “To help me come off street drugs. To stabilise me. That’s me probably contradicting myself as I’ve used on top”

• “I wanted 2 come off heroin without withdrawing so I was prescribed methadone and it made me feel normal or ok”

• At first I didn’t think I needed one. I changed my mind – It feels cleaner than heroin & it feels like I’m more supported, friends, family, even the chemist”

What are you prescribed?• “30mls methadone”• “85mg methadone”• “32mls methadone (currently on a 3ml per week

reduction from 70mls)”• “At the moment in time I’m prescribed 8 yellow

valleys (diazepam) each day and 30mls of methadone”

• “40mls methadone”• “30mls methadone”• “80 mls methadone”

How has your prescription helped you? (both physically and in other areas of your life)

• “Stopped me from withdrawing. I’d probably be at rock bottom, probably dead”

• “It has kept me off the heroin for the last 2 years”• “It has helped me with my baby boy. Being clean and drug free for him. So

all my attention is focussed on him. You counsel us as well, it’s not just the prescription”

• “Physically I can get up out of my bed without rattling and I can do what I want to do all day without running around trying to get smack”

• “My prescription helped with family because I wasn’t taking heroin, just my medication”

• Don’t feel weighed down worrying about money, heroin or health. Able to cope better”

Are there any negative effects of receiving a prescription?

• “You do not want to have to take methadone every morning but in my case I have to or I will be very ill”

• “Nope”• “Being supervised at the chemist, I bumped into my old

best friend and it was embarrassing”• “My teeth are rotting. I feel funny going into the chemist

everyday as they all know – it’s a wee bit embarrassing”• “I guess sometimes you wish you didn't have to go to the

chemist every day, feels quite a tie but when I think about before I prefer this to before”

How would your life be different if you hadn’t received a prescription?

• “Looking really unhealthy and skinny, looking 4 times as worse as before I went into secure”

• “I would probably be in the jail (stealing to get money for heroin)”• “Probably wouldn’t have my baby girl – cause you helped me when I was

pregnant. I probably would’ve had to have an abortion”• “I moved house recently – only did 3 trips. Moving in was 20 trips but sold

all my stuff”• “I probably wouldn’t be here to answer that if it wasn’t for the staff”• “I probably wouldn’t have fallen pregnant and I probably would’ve had him

taken off me as well” (on C P register)

What do you think about the assessment process for prescribing?

• “I liked doing the drug diaries”• Thought it was quite long. Asked me questions that I hadn’t

thought of before. Gave me a wake up call”• “Alright. Planning each day was over the top” (during detox)

*dad disagreed!• “It was a nightmare – to be honest, just because you expect it

straight away”• “The hardest bit was coming in withdrawing to see the doctor”• It was stressful but I was feeling happy at the same time

because I was getting a prescription”• “I think they are doing the right things, always have”

Is there anything that could have been done differently?

• No and I’m glad it has been done this way because I still have my life at the moment thanks to the doctor and nurse but we are still working together to sort this very weird problem out as quickly as possible”

• “I don’t like my chemist at all but nothing else”• “You do everything okay”• No. Not that I can think of”

Is there anything that could have been done differently?

• “I always wanted dihydrocodeine and diazepam as I thought they would be easier to come off. I think I was a bit young for methadone. I now think I should’ve tried Subutex. I think folk should try that first”

• “When I was on the detox, I had to come up every day and get checked every day. I would rather have stayed in my bed”

• “Not really, everything here was fine. Maybe I could have done things a little differently but I didn’t. I could’ve stuck to my prescription and not taken smack - don’t think I was ready it wasn’t the right time”

References• Crome IB, Christian J & Green C (2000) A unique designated

community service for adolescents: policy, prevention and education implications. Drugs Education, Prevention and Policy. 7, 87-108.

• Crome IB (2004) Treatment. In Young People and Substance Misuse. (eds Crome IB, Ghodse H, Gilvarry et al). London: Gaskell

• Department of Health (1999) Guidelines on Clinical Management: Drug Misuse and Dependence. Norwich:The Stationery Office.

• Health Advisory Service (2001) The Substance of Young Needs. London: Drugs Prevention Advisory Service, Home Office.

• Stewart DG & Brown S (1995) Withdrawal and dependency symptoms among adolescent alcohol and drug abusers. Addiction. 90, 627-635.