Health Care Standards Health Care Standard 10 Clinical Management of Drug, Alcohol & Tobacco Dependency Standard Statement The provision of evidence-based substance misuse management and support by competent, qualified and supervised professionals. 10.1 Health Care Standard 10 should be delivered taking account of Heath Care Standards 1, 5, 7, 8, 11, 12 & 13. 10.2 CRITERIA: Drug Dependency 10.2.1 Prescribing in relation to drug misuse and dependence should be carried out in accordance with the national guidelines - „The Orange Book., “Drug misuse and dependence: UK guidelines on clinical management” (2007) to reduce harm and promote recovery by adopting the following (10.2.1.1 – 10.2.1.8). 10.2.1.1 On admission prisoners reporting a history of substance misuse will provide a supervised sample of urine for drug analysis to aid treatment decisions. 10.2.1.2 Person-Centred Integrated Approach – Services are part of a coherent, planned package of care including access to wider addiction services and support utilising the Integrated Addiction Process (see appendix 1). 10.2.1.3 This integrated care plan should be recorded in the Health Care Record. 10.2.1.4 Continuity of care – continuing community prescribing where appropriate, both into and out of prison and include regular case review. 10.2.1.5 Initiation of substitute treatment – prison can offer a period of stability, reflection and access to treatment not usually accessed by prisoners when in the community. Treatment should be offered where appropriate and where a community prescriber has been identified to continue treatment after release. Prisoners should neither receive higher priority for their treatment nor should their legal status deny them equivalence of care. 10.2.1.6 Consistent prescribing – Prisoner groups should be treated consistently within prisons and on transfer between different prisons; treatment should not be withdrawn punitively in the event of relapse but should result in closer support and review by a multidisciplinary team. 10.2.1.7 Safe Prescribing - Dispensing of controlled medication should follow the Standard Operating Procedure on Controlled Drugs referenced in HCS 8. 10.2.1.8 Compliance monitoring – Clinical testing (urine dip testing) will be conducted regularly to confirm treatment compliance and monitor outcomes. 10.2.1.9 Establishments must ensure they have access to ECG equipment capable of recording and interpreting QT Intervals, have practitioners competent in ECG interpretation or have a system in place to ensure correct interpretation. 10.2.1.10 ECG monitoring is recommended prior to methadone treatment for prisoners with recognised risk factors for QT prolongation, eg history of cardiac anomalies, ischaemic heart or liver disease, or where concomitant treatment is provided with drugs that have a potential for QT prolongation eg some antipsychotic medication. A further ECG test will be conducted at dose stabilisation. 10.2.1.11 ECG monitoring will occur for prisoners who do not have risk factors for QT prolongation, before dose titration above 100mg daily and at seven days post titration. 10.2.2 Prisoners not in receipt of a substitute prescription on admission into prison should be assessed and offered detoxification, if appropriate, to manage withdrawal symptoms in accordance with SPS Operational Guidance (2010/11). 10.2.3 Prisoners engaged in injecting behaviour will be confidentially and discreetly offered a Harm Reduction Pack service in accordance with the “Harm Reduction Pack protocol” (2008) as an initial step towards substitute treatment. 10.3 CRITERIA: Alcohol Dependency 10.3.1 Alcohol dependant prisoners who have been assessed and in withdrawal on admission into prison should be offered alcohol detoxification treatment in accordance with the SPS Operational Guidance (2010/11). 10.3.2 Prisoners who indicate they have an alcohol problem should be referred to Addiction Services and/or appropriate Links Centre services for support. 10.3.3 Prisoners who disclose that alcohol was an influence at their index offence, or that they were intoxicated at the time, or that the notes and circumstances document such alcohol misuse, should be assessed as someone with an alcohol problem, and managed appropriately (pending a specialist assessment or screening tool). 10.4 CRITERIA: Tobacco Dependency 10.4.1 All prisoners should be offered Brief Advice by suitably trained staff. 10.4.2 16-18 year old prisoners, who are tobacco dependant but cannot purchase tobacco products, should be offered Nicotine Replacement Therapy free on prescription and access to smoking cessation services irrespective of sentence length. 10.4.3 Eligible prisoners who are tobacco dependent and wish to stop smoking should be offered access to services as outlined in “Smoking Cessation Guidance” (2009) 10.5 CRITERIA: Staff Training 10.5.1 Both Doctors and Addiction Nurses working in prisons will have completed (or be working towards completing) the RCGP certificate in Substance Misuse parts 1 & 2 or equivalent experience, and will maintain their expertise in Addictions Management as a core skill. REFERENCES: Drug Misuse and Dependence: UK Guidelines on clinical management. London. Department of Health (England), 2007 http://www.nta.nhs.uk/areas/clinical_guidance/clinical_guidelines/docs/clinical_guidelines_2007.pdf SPS Harm Reduction Protocol (2008) can be obtained from: http://spsportal/sites/HealthAndCare/addictions/Harm%20Reduction/Protocols/Harm%20Reduction%20Protocol%20Revised%20Jan%202008.pdf Smoking Cessation Guidance (2009) can be obtained from: http://spsportal/sites/HealthAndCare/Docs/Documents/SPS%20Smoking%20Cessation%20Guidance%20Jan%2009.pdf Changing Scotland’s Relationship with Alcohol: a framework for Action. Scottish Government, 2009 http://www.scotland.gov.uk/Resource/Doc/262905/0078610.pdf National Quality Standards for substance misuse services. Scottish Government, 2006 http://www.scotland.gov.uk/Publications/2006/09/25092710/7 Reducing harm and promoting recovery: a report on methadone treatment for substance misuse in Scotland. SACDM Methadone Project Group. 2007 http://www.scotland.gov.uk/Publications/2007/06/22094730/0 Review of Methadone in Drug Treatment: Prescribing Information and Practice. Scottish Government, 2007 http://www.scotland.gov.uk/Publications/2007/06/22094632/0 Review of the role of methadone in the treatment of drug problems: Consultation response. Scottish Drugs Forum, 2007 http://www.scotland.gov.uk/Publications/2007/06/22094703/0 Methadone and buprenorphine for managing opioid dependence. NICE Technology Appraisal. NHS, 2007 http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=11606 Essential Care: A Report on the Approach Required to Maximise Recovery from Problem Substance Use in Scotland. Scottish Advisory Committee on Drug Misuse: Integrated Care Project Group, 2008 http://www.scotland.gov.uk/Publications/2008/03/20144059/11 Integrated Care Project Group - Integrated Care for Drug or Alcohol Users: Principles and Practice. Scottish Advisory Committee on Drug Misuse, 2008 http://www.scotland.gov.uk/Publications/2008/05/27154207/9 The Road to Recovery: A New Approach to Tackling Scotland's Drug Problem. The National Drug Strategy for Scotland Scottish Government, 2008 http://www.scotland.gov.uk/224480 Scotland’s Future is Smoke Free: a Smoking Prevention Action Plan Scottish Government, 2008 http://www.scotland.gov.uk/Publications/2008/05/19144342/13 Better Health, Better Care Scottish Government, 2007 http://www.scotland.gov.uk/Resource/Doc/206458/0054871.pdf SPS Operational Guidance (2010/11) Appendix 1