Improving Clinical Responses to Drug-Related Deaths · Improving Clinical Responses to Drug-Related Deaths Dr Prun Bijral ... Identifying risk of drug-related death 2. ... Meeting

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Date:

Improving Clinical Responses to Drug-Related Deaths

Dr Prun Bijral

Medical Director

15th November 2017

© CGL 2017

DRD are preventable

• Highest for E+W since records began 1993

• Heroin deaths doubled between 2012 and 2015

© CGL 2017

5 Key Areas for Action

1. Identifying risk of drug-related death

2. Delivering safe, recovery-orientated drug treatment

3. Preventing overdose in people who use drugs

4. Meeting physical and mental health needs

5. Reducing the risk of DRD for people outside treatment

What the relevant guidance has to say, possible barriers to implementation, and solutions

Case examples not covered today, available in document

© CGL 2017

1. Identifying risk of drug-related death

Evidence to support identification of risk factors to overdose

• Male, older

• Not in treatment

• Entry and exit from treatment

• Reduced tolerance when leaving a secure setting

• Concomitant use of other depressants, with heroin

• Previous history of overdose

• Unstable accommodation, especially street or hostel

• Variable engagement

© CGL 2017

Identifying risk of drug-related death

• Considerations

• Paper-based data

• Inconsistency in recording

• Lack of focus on the most relevant data

• Variable accuracy in reporting cause of deaths by coroners

• Complexity not always recorded effectively

• Solutions

• Maximise benefits of EHR through discrete data points

• Analysis of data to allow risk-profiling

• Consider use of data-analytics, combined with traditional good practice of in-depth analysis of root causes

• Recognise importance of identifying complexity

© CGL 2017

2. Delivering safe, recovery-orientated drug treatment

Key points

• Critical to ensure treatment systems are balanced

• Opioid substitution treatment is protective

• Optimised interventions that are individualised

• Time-limited treatment increases risk

• Importance of maintaining therapeutic relationship (engagement)

© CGL 2017

Delivering safe, recovery-orientated drug treatment

Considerations

• Those at highest risk often require a holistic plan

• Possible over-emphasis on progress to abstinence

• Retendering will certainly impact on continuity of care

• Ability of services to consistently deliver evidence-based interventions as resources are constrained

Solutions

• Holistic plans and advocacy for equitable access to other services

• Informed consent and optimisation of dose

• Take-Home Naloxone

• Low-threshold offer

• Other options for those failing to benefit eg Heroin-Assisted Treatment

© CGL 2017

3. Preventing overdose in people who use drugs

Current guidance

• Importance of Needle exchange

• Education around OD and risk reduction

• Staff awareness

• Rapid access to OST

• Addressing use of alcohol and other drugs

• Recovery check-ups and Rapid re-entry

• Seamless transfer of treatment on release from prison

• Multiagency collaboration to identify those most at risk

© CGL 2017

Preventing overdose in people who use drugs

Considerations

• Can be hard to predict (unexpected life events eg bereavement)

• Optimisation of dose is not just when SU feels ‘OK’

• THN on release from prison not universal/core

• Needle ex engagement opportunities may be limited

• Availability of therapeutic options for those struggling to benefit

• Trauma-informed care is not widespread

Solutions

• THN must be considered core element of treatment

• Dynamic risk approach

• Tenacious approach to re-engagement

• Improve staff competency in dealing with trauma

© CGL 2017

4. Meeting physical and mental health needs

Current guidance

• All SU should have an assessment of general health needs

• Awareness of increased susceptibility to OD

• Recognise impact of smoking

• Awareness of appropriate pathways

• Staff should be able to recognise psychiatric crises

© CGL 2017

Meeting physical and mental health needs

Considerations

• PWUD most in need, but least likely to receive help

• Homeless, mentally ill or in CJ system struggle the most

• Mainstream systems can be difficult to navigate

• Experience of prejudice in a healthcare setting

Solutions

• Focus on developing robust pathways with senior-level oversight

• Improve staff competency

• Use of standardised assessments

• Empower SU to understand and support their access to services

• Co-location supports engagement

• Obvious cross-over with Hepatology and Respiratory Health

© CGL 2017

5. Reducing the risk of DRD for people outside treatment

Current guidance

• Understand treatment penetration for all groups

• Treatment should be accessible and attractive

• Needle Exchange remains a crucial access point to treatment

• Services should be culturally sensitive

• Particular consideration for hard to access groups

© CGL 2017

Reducing the risk of DRD for people outside treatment

Solutions

• Reduce waiting times

• Outreach is vital for hard to reach and engage

• Needle Exchange staff should have the appropriate skills

• Improve awareness of treatment amongst employers, first responders

• Support peers to promote treatment benefits

• Listen to SUs when developing services

• Widespread THN in high risk settings eg hostels

• Consider new initiatives such as Drug Consumption Rooms

• Excellent harm reduction may be enough for some

• Engage families and carers with THN, and support

© CGL 2017

Emerging issues – Fentanyl and related analogues

Fentanyl and related analogues

• North Americas opioid ‘epidemic’ and task force report

• Reversal in mortality rates

UK relevance

• Increasing number of deaths (60+)

• Largest share of darknet sales in Europe

• Local geography of trading

• Scale of problem and future risk unknown

• Opportunity to prepare is now – prevent, detect, control

• Solutions as above

• Must keep an open-mind to national and international initiatives

© CGL 2017

Useful Links

ACMD

https://www.gov.uk/government/publications/reducing-opioid-related-deaths-in-the-uk

PHE

http://www.nta.nhs.uk/uploads/phe-understanding-preventing-drds.pdf

CV/NHSSMPA

http://www.collectivevoice.org.uk/wp-content/uploads/2017/08/Improving-clinical-responses-to-DRDs-August-2017.pdf

Fentanyl round table report

https://www.changegrowlive.org/what-we-do/evidence-impact/reports/fentanyl-report-action-plan

Email: [email protected]

Tweet: @DrBijral