The document provides information about drug treatment and prescribing practices in Wirral, UK. It outlines the local drug problem, services available, and operational details of the Wirral Drug Service. Key aspects of the service include drug assessments, flexible methadone and buprenorphine prescribing, reviews with key workers and doctors, harm reduction initiatives, and programs to support recovery and treatment exit. The service aims to improve health, reduce drug use and related harms, and addresses the diverse needs of clients through a strategic, pragmatic, and humane approach to drug treatment.

1. Drug Treatment
and
Prescribing
Vincent Hessey

2. DANOS UNITS
AA3, AC1, AC3, AD1, AD4
• Understand the impact of substance misuse
in the locality.
• Be aware of services commissioned to
respond to the above.
• Understand how the service operates
strategically and on a day to day basis.
• Understand how to access the service and
treatments available.

4. Wirral Map
WALLASEY
BIRKENHEAD
WEST WIRRAL

5. WIRRAL DRUG SERVICE
 WIRRAL POPULATION circa 312,293 (census 2001)
 HEROIN ‘EPIDEMIC DURING’ 1980’s
 4475 DRUG USERS = 2.3 % of total population *
 WIRRAL HIV/AIDS PREVENTION UNIT( 1988)
 WIRRAL DRUG SERVICE (1991)
 CLIENTS IN TREATMENT 1500 (0.51% pop)
* 15-64 years population 195,566 source Centre for Public Health
LJMU May 2003 > Ratio ( 1in) 1-43

6. MISSION STATEMENT
WIRRAL DRUG SERVICE PROVIDES QUALITY ACCESSIBLE
INTERVENTIONS FOR THOSE WHOSE LIVES ARE
AFFECTED
BY DRUG USE, TREATING THEM WITH DIGNITY AND
RESPECT.
THE SERVICE RESPONDS TO THE DIVERSITY OF THE
COMMUNITY
AND RECOGNISES THE NEEDS OF INDIVIDUAL CLIENTS,
THEIR
FAMILIES AND CARERS.

7. NTA MID YEAR REVIEW MEETING
 A more recent piece of research focussing on drug treatment from a drug users
perspective, commissioned by the DAAT, has further confirmed that as far as
substitute prescribing is concerned, Wirral’s drug treatment system is probably as
good as it gets. That is not to say however, that things should remain as they are
indefinitely.
 Prescribing lies at the heart of any drug treatment system and will continue to
remain so as described in the Governments New Drug Strategy; the prescribing
system delivered across the Wirral and in particular by the Cheshire and Wirral
NHS Foundation Trust, remains one of the most pragmatic, flexible and humane
regimes we have encountered.

8.  The NTA look forward to assisting Wirral's drug treatment system to
evolve over the future lifetime of this new drug strategy and we expect it to
remain one of the most effective drug treatment systems the NTA currently
oversees
 Wirral continues to be one of our best performers and probably
represents the very best approach to tackling drug misuse that the
Governments last Drug Treatment Strategy aspired to. The New Drug
Strategy will certainly mean change and evolution for Wirral's drug
treatment system but we remain assured and confident that it is already
responding to the challenge that the new drug strategy represents.
MARK HARRIS
NW DEPUTY REGIONAL MANAGER
NATIONAL TREATMENT AGENCY

9. DRUG PATHWAY
W IR R A L
DRUG
S E R V IC E
GP FULL OTHER
REFERRAL DRUG AGENCY
ASSESSM ENT
H O S P IT A L THE THE SELF
REFERRAL R E V IE W PR O JEC TS REFERRAL
TEAM TEAM
T R IA G E C R IM IN A L J U S T IC E
Criminal Justice D U A L DOTCN O S I S
IA G
ASSESSM ENT S O CHostels R E
IA L C A Dual HDiagnosis
P S Y C O L O G IS T
R E V IE W S Young E L S
H O S T People C O MPDL Caseload T S
P E X C L IE N
P DSocialE Care D
CAS LOA Y OPsychologistE
UNG PEOPL
4 YO
SHARED CARE HARM
& R E D U C T IO N
RECOVERY TEAM
TEAM R
Treatment
Exit
Team

10. ASSESSMENT
 REASONS FOR PRESENTATION
 DRUG HISTORY (PAST & PRESENT)
 HISTORY OF INJECTING (HIV, HEP C)
 MEDICAL HISTORY
 PSYCHIATRIC HISTORY
 FORENSIC HISTORY
 SOCIAL HISTORY
 PAST CONTACT WITH SERVICES
 URINALYSIS
 OTHER INFORMATION

11. ASSESSMENT
EXAMINATION
 MOTIVATION
 GENERAL HEALTH
 MENTAL HEALTH
 SOCIAL CIRCUMSTANCES
 FAMILY ISSUES
 HOUSING / HOMELESS PROBLEMS
(DRUGS MISUSE and DEPENDENCE - CLINICAL GUIDELINES)

12. REASONS FOR PRESCRIBING
 IMPROVE CLIENTS HEALTH
 REDUCE DRUG USE ( ILLICIT & PX)
 ADDRESS DRUG RELATED PROBLEMS
 REDUCE DRUG RELATED HARM / DEATHS
 REDUCE DURATION OF DRUG USE EPISODES
 REDUCE CHANCE OF FUTURE RELAPSE
 REDUCE NEED FOR CRIMINAL ACTIVITY
 REDUCE RISK OF PRESCRIBED DRUGS
BEING SOLD ILLEGALLY

13. ASSESSING MOTIVATION
Rather than testing whether the applicant
“really” wants to change, clinicians should
welcome the opportunity to demonstrate to
clients the benefits of treatment. The challenge
in drug treatment should not be to test
motivation, but to foster it, and to maximise the
likelihood that the individual will benefit from
treatment. KEY ISSUES IN METHADONE MAINTENANCE TREATMENT
JEFF WARD, RICHARD MATTICK, WAYNE HALL

14. METHODS OF PRESCRIBING
 METHADONE MIXTURE 1mg/1ml, 10mg/1ml
 METHADONE REEFERS 30mg, 60mg.
 METHADONE AMPOULES 50, 35, 20, 10 mg
 METHADONE TABLETS 5mg
 DIAMORPHINE AMPOULES / REEFERS
 BUPRENORPHINE (SUBUTEX)
 BENZODIAZEPINES
 ANTIDEPRESSANTS / ANTIPSYCHOTICS
 LOFEXEDINE / NALTREXONE

15. WHAT TO PRESCRIBE
 ASCERTAIN ILLICIT DRUG USE
 INITIAL DOSAGE (30 mg)
 SUPERVISED CONSUMPTION
 ORAL METHADONE
 DAILY PICK UP
 TITRATE DOSAGE
 REVIEW

16. POLICIES AND PROCEDURES
 MISUSE of DRUGS ACT 1971
 CHILDREN ACT 1989/2004
 TACKLING DRUGS (Government Strategy)
 NATIONAL TREATMENT AGENCY
 MODELS OF CARE
 CLINICAL GOVERNANCE (PRCISE)
 DANOS
 QUADS

17. REVIEW
 KEYWORKER /CLIENT - 3/12
 ASSESS DRUG USE
 ASSESS CURRENT MEDICATION
 REVIEW HEALTH / MENTAL HEALTH
 SOCIAL CIRCUMSTANCES / PROBLEMS
 CHILD PROTECTION ISSUES
 FORENSIC
 EMPLOYMENT STATUS
 CLIENT MOTIVATION
 CARE PLAN/ RISK ASSESSMENT/ URINE

18. DOCTORS REVIEW
 DOCTORS REVIEW 6/12
 ASSESS CURRENT PRESCRIPTION
 ASCERTAIN CURRENT DRUG USE
 ADDRESS HEALTH / MENTAL HEALTH
 REFER TO OTHER SERVICES
 CARE PATHWAY APPROACH
 INCREASE / DECREASE SCRIPTS
 DISCUSS FUTURE PLANS

19. Trans-theoretical Model of Behaviour
Change
Preparation stage Action stage
I prepare to stop/reduce I stop using drugs
the amount of drugs I use
Relapse
I start to use drugs again
Contemplation
I perceive a link Maintenance / Recovery
between my drug I continue not to use drugs
use and my health
Precontemplation
I believe there is no link
between drugs and my health
Prochaska and DiClemente’s
Wheel of Change (1991)

20. Precontemplation -- Where there is no intention to change
behaviour in the foreseeable future .
Contemplation -- Where there is awareness that a problem
exists and one is seriously thinking about
overcoming it but has not yet made a
commitment to take action.
Preparation -- Where the person is intending to take action
soon and may have already unsuccessfully
taken action during the past year.
Action -- Where the person modifies the behaviour,
putting in a considerable amount of time
and energy, which is obvious to others.
Maintenance -- Where the person works to prevent relapse
and consolidates the gains of the action
stage. This stage may go on for a long time,
possibly a lifetime.

21. REVIEW TEAMS
• 400 CLIENTS
• 8 WORKERS
• ENGAGEMENT /OUTREACH WORKERS
• REVIEW CASELOADS
• DIAMORPHINE TREATMENT

22. PROJECTS TEAM
• 275 CLIENTS
• CRIMINAL JUSTICE PRACTITIONER
• HOSTELS/HOMELESS & YOUNG PERSONS
LINK
WORKER
• SOCIAL CARE CASELOAD / CO-
ORDINATOR
• SUBSTANCE MISUSE WORKER

23. PROJECTS TEAM
DUAL DIAGNOSIS / MENTAL HEALTH NURSE
CLINICAL PSYCHOLOGIST
(PERSONALITY DISORDERS)
4 YEARS + CLIENTS (4YO)
SUBSTANCE MISUSE PRACTITIONER
(PERSONALITY DISORDERS)
OVER THE COUNTER PRACTITIONER

24. HARM REDUCTION CENTRE
• NURSE LED SERVICE
• NURSE PRESCRIBING
• HEP C PATHWAY NURSE
• HOMELESS NURSE PRACTITIONER
• SYRINGE EXCHANGE
• CONFIDENTIAL TESTING
• SEXUAL HEALTH CLINIC
• STEROID CLINIC
• STIMULANT NURSE
• WOMENS SERVICES
• ALCOHOL NURSE PRACTITIONER
• PHARMACY LIAISON WORKER
WIRRAL DRUG SERVICE

25. SHARED CARE & RECOVERY
TEAM
• 16 WORKERS
• 780 CLIENTS (700/80)
• 100% WIRRAL GP’S
• GP TRAINING
• RCGP ACCREDITATION
WIRRAL DRUG SERVICE

26. SHARED CARE & RECOVERY
TEAM
• VARIETY OF PRESCRIBING
OPTIONS
• ALTERNATIVE THERAPIES
• DETOX TRANSITION
• RECOVERY PROGRAMMES
• REFER TO AFTERCARE

27. Treatment Exit Team
• Stable Clients
• Reducing off Script
• Regular Contact
• Therapeutic Interventions
• Prepared to exit within 3-6
months as drug free

28. REFERENCES & LINKS
DRUGS MISUSE and DEPENDENCE - CLINICAL GUIDELINES
DOH PUBLICATION
TACKLING DRUGS TO BUILD A BETTER BRITAIN (1998)
WWW.WIRRALDRUGSERVICE.ORG
METHADONE BRIEFING (ANDREW PRESTON)
KEY ISSUES IN METHADONE MAINTENANCE TREATMENT
( JEFF WARD, RICHARD MATTICK, WAYNE HALL )
Applications to Addictive Behaviours, (James 0. Prochaska, Carlo C. DiClemente and John C. Norcross)
(pp. 1102-1114 Vol. 47, No. 9), (1991)
FIRST INTERNATIONAL CONFERENCE ON HARM REDUCTION
(Newcombe,1991)
INSTITUTE FOR STUDY OF DRUG DEPENDENCE (1996)