2.1 Where the client is in a local prison the DIP In-Reach worker will undertake a full comprehensive assessment, and will specifically focus on the following areas:
Previous treatment interventions and response i.e. what, when and success or otherwise. Clearly where a client’s circumstances do not indicate previous consistent engagement with treatment agencies towards establishing a stable and managed position regarding their drug use, and preferably some indication of previous attempts to withdraw from opiates, then it may be reasonable to take the view that naltrexone might not be the best option.
Exceptions to this may include a long prison sentence where the client has clearly engaged consistently with treatment and support agencies in the prison and in the community, and has developed a clear perspective on naltrexone prescribing as part of a detailed treatment package upon release.
Liver Function Test (LFTs) clearly indicate the suitability of the client
Accommodation – must be stable and settled accommodation, with no other drug users indicated as present at the accommodation
Social support networks – range of support that will reinforce a drug free lifestyle
Lifestyle and associates – no indication of close and primary contact with a drug using group of friends/family
Prepared to engage with Harm Reduction and Relapse Prevention work as part of a comprehensive treatment package
Employment/training opportunities either identified or prepared to explore as part of comprehensive treatment package
If all these criteria can be met then the individual would be suitable for Naltrexone prescribing, under supervised conditions.
2.2 Where the client is not located in a local prison then the DIP Throughcare and Aftercare Care Coordinator will work with the CARAT and Healthcare staff within the relevant prison to ensure that a triage assessment, incorporating the key areas for assessment as noted above, is completed and a copy faxed to the care coordinator.
2.3 Having received the relevant information and reviewed any history of contact with treatment services that may be available, the DIP worker will review the referral for naltrexone prescribing with the clinical lead for DIP. Where the assessment indicates that all or most of the assessment criteria are met, referral for naltrexone prescribing will progress, as usual, via the CDT team meeting in the relevant area. This will include identification of drug worker, where DIP worker is unable to hold clinical responsibility for the case at that time, but where the DIP worker would continue to act as care coordinator in relation to the Care Plan. Transition to shared care should be instigated within a two week period.
2.4 Where an agreement in principle to naltrexone prescribing is indicated at the CDT meeting, the assessment and details of the case will be presented to the Consultant, in paper form, and an agreement to support naltrexone prescribing confirmed.
2.5 The prison will be informed of the decision as to whether Worcestershire CDT are able to support the prescribing of naltrexone on release
a Where naltrexone can be prescribed on release – (see prescribing guidelines Department of Health) the prison will be informed in writing and this will involve them undertaking all the necessary clinical tests prior to commencing naltrexone prescribing before release. The prison would normally release with up to 7 days supply of naltrexone. An early appointment with the Consultant will be arranged within seven days post release, when the continuation script will be confirmed and Care Plan including comprehensive treatment package to support naltrexone prescribing regime confirmed.
b Where naltrexone cannot be prescribed on release. – the prison will be informed in writing with reasons as to why the client does not meet the local assessment criteria, or if for clinical reasons the use of naltrexone is contra indicated. CARAT
client prior to release. An early appointment with DIP throughcare and aftercare worker will be confirmed upon release and a detailed review of alternatives and a Care Plan completed. This may include working with partnership agencies with regards to relapse prevention.
2.6 Where naltrexone prescribing is indicated – case will be reviewed with the medic. Liver function tests need to be undertaken, and the frequency of these will depend on past history of liver problems, obesity, alcohol use, older adults and at the request of the medical practitioner (prescribing guide lines state liver function tests should be carried out prior to, and throughout the treatment period) these results may be required at the formal reviews.
2.7 Normal period of naltrexone prescribing would not exceed 12 months, and more routinely work would be undertaken with the aim, given an appropriately targeted individual in the first place, of supporting withdrawal between 3 and 6 months
Worcestershire Mental Health Partnership NHS Trust Substance Misuse Service
Assessment Form for the use of Naltrexone
Name Home Address
Prison and Prison No.
Pregnant YES NO
History of previous Treatment
Interventions
Successful or otherwise.
Has there been previous consistent engagement.
Have there been previous attempts to withdraw from opiates.
Compliance to treatment Accommodation
Are drug users indicated as resident at this address, is it a settled stable environment Liver Function Test Results Social Support Networks What support is there to reinforce a drug free lifestyle?
Prepared to engage with harm reduction and relapse prevention work
Employment/Training Opportunities
Please complete tick boxes if client fulfils the criteria in all area then in principal they would be a suitable candidate for prescribing
Yes No History of previous treatment
Accommodation Liver Function Test
Social Support
Lifestyle and associates
Prepared to engage in Harm Reduction/Relapse prevention Employment/Training opportunities
Name and Signature Of assessor
Assessment Date Further Action Required
Proposed Care Pathway Prescribing Naltrexone within the community teams
Worker will
undertake a SMS Naltrexone Assessment Form
If suitable If not suitable
Discuss further treatment options with the client and signpost to the appropriate services Appointment made
with prescribing specialist (Consultant)
Shared care arrangements should be delineated
Discuss with relevant clinical lead
for the team an present at clinical
meeting
Consultant Confirms Prescription
Proposed Care Pathway Prescribing Naltrexone
If suitable If not suitable
Communication with
Propose Care Pathway Prescribing Naltrexone
20 Appendix 4
The following is aimed at helping the service user and keyworker/care co-ordinator to draw a comprehensive care plan during the preparatory process for detoxification program and for after care:
Service User Name: Keyworker: Date:
1. Identify and please list high risk situations/triggers for craving which could lead to relapse into drug taking behaviour following the completion of detoxification program?
2. Please list the strategies you have considered and developed to avoid or limit exposure to high risk situations?
3. List below the skills you have considered and developed to manage cravings and other painful emotions without using drugs?
4. Print below the relapse prevention plan to cope with lapses into drug taking behaviour?
5. What is your action plan to recognise, challenge and manage unhelpful or dysfunctional thoughts about drug misuse?
6. What is your emergency plan for coping with high-risk situations when other skills are not working?
7. What is your action plan to recognise how you might ‘set yourself up’ to use illicit drugs?
8. Please list the skills you have developed and engaged in generating pleasurable sober activities and relationships, improving quality of life and attaining a lifestyle balance?
21 Flow chart
Service user expresses the wish for opioid detoxification
Case discussed at Referral / team meeting in presence of Turning Point staff
Clinic appointment booked in 1-2 weeks time
If considered suitable, preparation work to draw up a clear care plan Assessments completed from Community Rehab and or Turning Point Care Co-ordinator to liaise care between different agencies
Clinic appointment booked and detox program decided
In-patient detox community detox
Assessment for Naltrexone treatment program
After care to maintain abstinence and relapse prevention
Joint working between Care Co-ordinator, CDT staff (Naltrexone treatment), Community Rehab, Turning Point for a period of at least 6 months
23 Useful References
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