How Clinicians can use CareCreds to help Class A Drugs addiction

Dr Mike D'Souza MD

"I spent my 35yrs as a family doctor wondering why more could not be done to reduce the chronic unhappiness, ill-health and emotional stress caused by addiction. Then six years ago, after accumulating over 30 young patients with severe and life-threatening Class A problems, I started experimenting with this CareCreds scheme. The results for these patients were remarkable; 87.3% became street clean in a matter of months and a third came off drugs altogether. I then realised that since this approach had been so helpful for such a difficult cases, it might prove even more useful in less desperate situations and so the present service can also be used by people with milder forms of addiction"

The poet Coleridge who had severe Class A addiction
(1) To use CareCreds to attract as many chaotic patients as possible to join a personal clinical care service.
(2) Then to use CareCreds to increase the uptake of health measures such as
      (a) Hepatitis/AIDs screening  (b) Hepatitis immunisation (c) Needle exchange &  (d) Condoms and Depot contraceptives. 
      Also to use CareCreds to
(3) Help patients stop using street and other addictive drugs altogether and to no longer let dealers have their mobile numbers.
(4) Help them become stabilized and keep wanting to stay with the same personal care service.
(5) Help them adopt stress reducing lifestyles. To do more physical exercise try CBT, Mindfulness and  to escape the frequently associated personality problems.

     Then when they are stable and street clean to incentivise them
(6) To stop all substitute medications and alcohol etc  and when mutually agreed proceed with Home Detox.
      Then If Home Detox is successful
(7) To use CareCreds to encourage them to continue Home Rehab, to get employment and to become socially reintegrated.
(8)   Finally to encourage each patient to feel liberated enough to enjoy pursuing a more sensible lifestyle of their own accord.
      Patients who do this for nine months are "ECBC graduates" and if receiving subsidized CareCreds they switch to DIY Carecreds untill they have completely recovered. Even then we advise continued longterm low level contact and monitoring because of the continuing risk of restarting drug misuse at times of stress etc. Our existing scheme of mobile phone checkups can be useful to help with this monitoring not least because CareCreds can be quickly reinstated if there is a relapse.

Our Clinical Strategy with Substitute medication
Before accepting a patient for regular treament,
1 Establish that they are genuine users of Class A drugs by testing urine.
2 Explain, politely, that  because drug taking is known to make people lie, confirmation by truly random tests for street drug use will be needed to verify any claims they make.
3 Once tested as positive for opiates prescribe substitutes accordingly (See opiate equivalence chart)  remembering that most street drugs are often cut to 30% of pure. Benzodiazepines should only be added to the script if they are already being used.
4 Enter all interested patients into the CareCred Scheme using one of our Co-op cards. Send us an SMS text to enter the patients ( or you can go to this site and fill in our on-line new patient entry form. Remember some patients find reading difficult and will need a verbal explanation.
5 When they are ready to listen explain how stress may have been involved to both trigger and worsen Depression, Substance Abuse and Personality problems and that Carecreds will help reduce both this and encourage them them to get health protection. Plan for HIV screening, contraceptive care, Hepatitis screening and immunisation. Also arrange a proper clinical examination of heart, lungs, injection sites etc.
6 Most  patients will need Scripts for opiate substitutes titrated according to need. These should be issued for Daily supervised consumption but they may have their Sunday's dose as a takeaway with Saturday's.
7 At least monthly follow ups will be required when validated CareCred scores can be texted to us (or our on-line follow up form used).   An important mark of a patient becoming stabilized will be their changing their mobile number and cutting contact with their past suppliers, so please notify us of this. Remember we will be contacting them to go for Random Urine drug tests every month to a place that you arrange. 
8 As soon as they are stable offer weekly scripts with rules of care i.e they will revert to having Daily scripts and even supervised scripts if they become unstable and use street drugs. (fear of losing their right to weekly scripts works as a valuable disincentive to relapsing back into street use)
9 Also offer Vitamin B and prescribe exercise. Where necessary treat Depression, Alcoholism and other addictions.
10 When their life is stable e.g. 3 to 6 months proven street clean and when it is mutually agreed it might succeed, attempt Home Detox.

Home Detox Plan:

(i) Reduce methadone by one eighth every month till 25 ml daily on weekly scripts.

(ii)  Taper Methadone fortnightly reducing scripts by one ml per diem Or for short-term users offer a faster Subutex detox if patients wish.

(iii) When off drugs continue to follow up monthly with ECBC recording for nine months

(iv) All those who remain clean may then be discharged from the scheme as ECBC graduates.
(v)  Continue relapse surveillance for decade or more(!).
Because addicted patients are obsessed with obtaining drugs, their behaviour often provokes stressful conflict. We have found that a key to their successful management is to completely ignore their bad or rude behaviour and only talk to their currently hidden sensible personality. It is remarkable how often patients calm down and become constructive when this approach is used. However if you or your staff get so upset that you feel something must be done, then we recommend that rather than have a futile mutually stressful argument with them, report the event on our Report good or bad behaviour page on this Website so that their CareCred earnings are reduced. Reducing stress by avoiding unnecessary conflict is important to maintaining a therapeutic relationship. Also being prompt with the availability of routine prescriptions and giving crisis scripts with small doses of substitute medication is more clinically helpful than arguing with people who have become regressed due to the state of their craving. When they eventually calm down many patients have little or no recall of just how bad their behaviour has been, particularly if they have severe personality problems. 

 Clinicians can ONLY be accepted for participation in ECBC by filling in our Registration Form and providing us with their  professional body registration numbers as validation.