Our Clinical Strategy with Substitute medication
Before accepting a patient for
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.
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.
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
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.
(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.
When off drugs continue to follow up monthly with ECBC recording for nine months
those who remain clean may then be discharged from the scheme as ECBC graduates.
(v) Continue relapse surveillance for decade or more(!).
POINTS ON PATIENT MANAGEMENT
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.