Models of care for treatment of adult drug misusers: Update 2006
technology appraisals of methadone and buprenorphine (for opiate maintenance treatment) and of naltrexone (for relapse prevention). The “clinical guidelines” will be updated alongside the development of the NICE work for 2007.
Substitute prescribing alone does not constitute drug treatment (NTA expert prescribing group, 2002). A community prescribing intervention should be provided within a care-planned package of care with an identified keyworker. It should be aimed at addressing the range of identified needs. The care plan should address drug and alcohol misuse, health needs, offending behaviour and social functioning. Interventions to tackle drug misuse problems may include:
Hepatitis B vaccination and HIV and hepatitis testing
Treating drug-related infections, e.g. abscesses
Harm reduction and health promotion interventions e.g. overdose prevention, use of naloxone, sexual health advice and needle exchange
Provision of, or access to, psychosocial interventions and support, e.g. motivational interventions.
The care plan may also include interventions to tackle problems in the other domains, and may include:
Provision of, or access to, interventions to address other psychological health needs, or mental health needs
A range of abstinence-oriented interventions e.g. mutual support groups (including 12-Step)
Assisting with access to suitable housing, employment, education and training opportunities, and childcare, as required.
The keyworker is responsible for ensuring that all components of the community prescribing treatment programme work together to help clients achieve the goals set out in their care plans.
There are a number of treatment settings where community prescribing takes place, which can be broadly grouped as GP prescribing and specialist prescribing.
Commissioners should ensure local treatment systems have a complete spectrum of medical provision to meet the range of needs and numbers of substance misusers. This requires a variety of skills and competences at various levels, from general medical skills to GPs offering less complex drug treatments under enhanced contracts, to specialist addictions skills and addiction psychiatry skills. This is a key message arising from the consensus document produced by the Royal College of General Practitioners and Royal College of Psychiatrists’ Roles and Responsibilities of Doctors in the Provision of Treatment for Drug
and Alcohol Misusers (2005),30
as summarised in an NTA briefing
note on the NTA’s website. www.nta.nhs.uk.
9.4.1 GP prescribing
GP prescribing is community prescribing for drug misuse which may be carried out in a primary care setting through a primary healthcare team, consisting of GPs and other primary care staff (depending on contractual arrangements). This is normally assisted or supported by a specialist drug team. The clinical guidelines advise against GP prescribing without such support.
A number of models of primary care drug treatment have evolved in the context of local resources and identification of need. These models include various types of shared care services in which GP services are supported by more specialist service provision, and primary care-led drugs services which do not have shared care arrangements with a secondary care provider. For more details on these, see section 3.5.4.
GP prescribing should be provided within a care plan with regular keyworking, and provision of appropriate psychosocial or other interventions as required. Different degrees of care planning may be appropriate in different primary care arrangements (NTA/RCGP 2004)51. The care plan should also address drug and alcohol misuse, health needs, offending behaviour and social functioning. In some practices, the GP will assume the keyworker role, but more commonly the shared care or primary care worker will take on this responsibility in collaboration with the GP. For more on care planning in primary care, see the Care Planning Practice Guide.
GP prescribing should be guided by the Department of Health’s clinical guidelines. These cover arrangements for daily dispensing, for shared care support and for the provision of supervised consumption through community pharmacies.
The client group in primary care has traditionally been drug users who are stable on substitute medication or whose problem level is mild to moderate. However, the exact nature of the clients treated and how the prescribing takes place will depend on the skills and competences of the GP and the degree of skilled multidisciplinary support. The guidance document Roles and Responsibilities of Doctors in the Provision of Treatment for Drug and Alcohol Misusers (2005) specifies a hierarchy of roles for GPs, with increasing competency levels:
GPs providing core services
GPs providing enhanced services
GPs with special clinical interest (GPwSI) providing enhanced
Substance misuse specialist (primary care).
These competency levels are described in more details in section 3.5
GP prescribing services may also be supported by non-medical prescribers, such as nurses and pharmacists, as well as other staff who are competent to provide drugs interventions, such as