Effective Interventions Unit Integrated Care Pathways Guide 5:
Community Detoxification pathways
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WHAT IS THE PURPOSE OF THIS GUIDE?This is the fifth guide on developing and implementing Integrated Care Pathways (ICPs). This guide offers an outline pathway, providing information to inform consistent evidence based practice in the planning and delivery of community based drug detoxification. WHO SHOULD READ IT?Those involved in commissioning, planning, delivering and evaluating community based drug detoxification services. This potentially includes health and social care staff from the statutory and voluntary sectors. It will be of particular interest to individuals, agencies and DAATs that are considering developing or reviewing community detoxification services in their area. |
BACKGROUND TO ICP GUIDES
The Effective Interventions Unit (EIU) launched Integrated Care for drug Users: Principles and Practice in October 2002. In response to the interest from the field in developing evidence-based care systems the EIU undertook to produce guidance on Integrated Care Pathways. The first four guides provided the core technical information on developing and implementing ICPs. Guide 5 is the first in a series of thematic guides which seek to apply these principles to practical situations.
This Guide contains information on: Background to ICP Guides What is Community Detoxification? Why Community Detoxification is important Consistency of Approach Issues to Address Structure and Content of an ICP Evaluation of ICP Next Steps and Other Resources
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WHAT IS COMMUNITY DETOXIFICATION?
Detoxification should be seen as a process that aims to achieve a safe and humane withdrawal from a drug of dependence1. Drug treatment services will assess whether this process should be carried out in a hospital or residential setting, or whether it can safely be undertaken in the community. Factors that would influence this decision would include the social circumstances and preferences of the individual, their current state of health and past medical history and resources available locally to provide this.
WHY COMMUNITY DETOXIFICATION IS IMPORTANT
Community detoxification can be an important step in the journey from drug dependence to a drug-free lifestyle. Even if clients (re)lapse (a frequent occurrence), what they have learned from the experience of detoxification can help them when undertaking some other form of treatment or a future attempt at detoxification. Detoxification should be regarded as a positive treatment intervention, used when a person has worked towards this goal and has spent time preparing physically, psychologically and socially for this change. Occasionally detoxification is entered into for different reasons: because of excessive waiting times for methadone maintenance programmes or because a client's current maintenance programme has been interrupted due to imprisonment or other unforeseen circumstances. Whatever the circumstances the detoxification should be planned and managed as part of a broader package of care designed to address the assessed needs of the individual.
CONSISTENCY OF APPROACH
Each of the 22 DAATs in Scotland state that community detoxification services are provided by agencies in their area - Corporate Action Plans (2003) 2. Drug Misuse and Dependence: Guidelines on Clinical Management (1999) 3 provides guidelines covering treatment including general principles, assessment, management of withdrawal and dependence and preventing (re)lapse. However, there is scope to improve aspects of the monitoring arrangements in place or planned in order to gauge the extent to which these guidelines are followed in practice. The development of local ICPs for community detoxification should reflect national UK guidance, thereby promoting a degree of consistency of approach across Scotland.
ISSUES TO ADDRESS
The key to the design and delivery of integrated care is to maintain the person-centred focus. Here we identify some of the issues that will need to be addressed when developing and implementing a person-centred ICP for community detoxification. We have set out these issues under the key elements of Integrated Care: Accessibility, Assessment, Planning and Delivery, Information Sharing, Monitoring and Evaluation.
ACCESSIBILITY
Community detoxification is not without risk. Reduction in tolerance to opiates following detoxification increases the risk of overdose in clients with a large, chaotic or injecting drug problem.
ICPs should identify clear referral criteria and entry points in order that the most appropriate support can be offered at the right time to the right person in the right place.
Community detoxification usually takes place over a number of days or weeks, often requiring the client to attend a community drugs service or GP surgery on a daily basis for all or part of this time. This may create difficulties for clients with young children, clients in employment, those who are homeless and those living in rural and remote areas with poor transport links: some clients may incur out-of-pocket travelling expenses. The ICP should acknowledge these issues as potential failure points, leading to variances, and seek to minimise the chances, wherever possible, of clients' defaulting.
ASSESSMENT
The purpose of assessment is to identify the needs and aspirations of the individual in order to inform decisions about treatment, care and support for drug users. As a result of the assessment process, the individual and their keyworker should have an understanding of the physical, psychological and social support required as part of the detoxification process. Effective assessment is an ongoing process and should feature throughout the pathway, initially to determine whether this pathway best meets the client's needs, again prior to commencing any substitute medication such as methadone (tolerance testing) or when considering using adrenergic Alpha 2 agonists such as Lofexidine to alleviate side effects of withdrawal.
There is often useful information to be sought from family members, friends or others including care providers who have had recent contact with the individual. Often this is the best source of qualitative information about how a person's drug use or detoxification is affecting them and those around them.
Assessment tools are used in a range of sectors to aid the assessment process. The ICP development group should be aware of the relative merits of each tool and select tools that will provide the required information at the appropriate stage(s) of the process. The EIU document, Digest of Tools Used in the Assessment Process and Core Data Sets (2003) provides useful guidance.
PLANNING & DELIVERY
In 2002 the EIU published The Effectiveness of Treatment of Opiate Dependent Drug Users: An international systematic review of the evidence. This review identified a relapse rate for community detoxification of between 19% and 83%. Process mapping the current situation in a local area should help to identify potential exit points from the ICP ( ICP Guide 2). Wherever possible, these exit points should act as junctions between ICPs. Arrangements should be in place to offer support in a timely and appropriate manner whenever relapse occurs.
The planning of the care that the individual is to receive should largely be dictated by the structure and content of the ICP itself. The review also stated that, "Intensive counselling or behavioural treatment had a considerable beneficial effect on retention and abstinence. Some form of counselling and behavioural treatment should be an integral part of detoxification." Given the nature of detoxification, the ICP should have an emphasis on the physical needs of the individual. The keyworker or care co-ordinator should ensure that the psychological and social support required is also delivered at the appropriate points.
INFORMATION SHARING
The purpose of sharing personal information on individuals between partner agencies is to ensure access to the appropriate treatment, care and support services for those individuals. The ICP will require a number of different agencies and individuals within those agencies to be working together on behalf of the client to help them reach an identified end point. The appropriate sharing of information will be a key factor in achieving this. Further guidance on the legal and ethical issues involved in information sharing can be found in Chapter 6 of Integrated Care. The ICP development group should consider including an information sharing strategy as part of the ICP documentation. This would highlight occasions when information should be shared including:
following initial assessment when community detoxification is being considered.
following comprehensive assessment when the care plan is being formulated.
prior to commencing the community detoxification.
during the pathway at planned handover points, where one agency or worker completes their involvement with the client and passes the care on to another.
when the needs of the client and/or their dependents change during the course of the pathway leading to additional or different support requirements.
when a client is reaching the completion of the pathway, the planned aftercare arrangements should be accessed.
following exit from the pathway all agencies and individuals involved should be informed of the outcome(s) and have the opportunity to reflect on, and evaluate, the care provided.
MONITORING
Monitoring is an ongoing process involving the continuous and regular collection of key information on the inputs, outputs and outcomes of a service, intervention or partnership. The main aim of monitoring is to establish if something is going to plan, and whether any change in activity is necessary.
One of the main reasons given for clients not completing a detoxification programme is the difficulty in managing the withdrawal symptoms. Symptoms of acute opiate withdrawal initially include anxiety, restlessness, difficulty sleeping, yawning, sneezing, and coughing, often followed by tremors, muscle twitching, chills and abdominal cramps. In more severe cases nausea and vomiting, diarrhoea, fever and rapid heartbeats (tachycardia) can occur. Following abrupt cessation of opiates withdrawal, effects can be evident after six hours, peak after 36-72 hours, and then gradually reduce over the following 5-10 days. However, some effects can persist for months particularly anxiety, depression, insomnia and fatigue.
The ICP development group should ensure that staff have appropriate skills, knowledge and expertise to identify and manage the symptoms of withdrawal, pertinent to their involvement in the ICP and that the ICP documentation includes instruments and/or rating scales to assist in this process.
Clients should play an active role in the monitoring of their own health and healthcare. ICP Guide 2 provides information on developing a client version of the pathway. For community detoxification this might include self-rating scales for anxiety and withdrawal symptoms and a chart for clients to monitor their own sleep pattern. It could also include an appointment card and contact telephone numbers.
EVALUATION
Evaluation is a systematic assessment of whether a service, intervention or partnership has achieved its stated aims and objectives. Evaluations commonly address questions about effectiveness, efficiency and acceptability. Evaluation can address the context and process of an intervention as well as the outcomes achieved.
ICP Guide 2 provides information on identifying key indicators or milestones against which you and the client can measure the progress of their care along a pathway. Key indicators for a community detoxification ICP might include severity and management of withdrawal symptoms, abstinence, retention in treatment and client satisfaction.
Further information on the evaluation of ICPs is included in ICP Guide 4.
STRUCTURE AND CONTENT OF AN ICP
An ICP is a set of documentation based on an agreed process which assist the individual and the agencies involved in their care to navigate their way through the process to an agreed and identified end point. The documentation normally combines a series of documented forms and a flowchart (process). An ICP also outlines agencies and disciplines involved in care management, locations of care providers and guidelines on assessment and substitute prescribing.
The Co-ordinated Addictions Network in Argyll and Clyde has developed an ICP for Opioid Detoxification. It includes a set of documented forms and a flowchart (process). We have adapted it below:
Flowchart (process)
NEXT STEPS AND OTHER RESOURCES
All EIU documents referenced in this Guide and planned future ICP Guides and ICP dissemination events can be viewed on the EIU website: www.drugmisuse.isdscotland.org/eiu.htm
The EIU welcome comments on their work outputs.
Thanks to the ICP Development Group, Figure 8 Consultancy Ltd and others for contributing to this guide. |
Footnotes1 Mattick RP & Hall W, Are detoxification programmes effective? Lancet. 1996 Mar 30;347(9005):904.
2 Corporate Action Plans - http://www.drugmisuse.isdscotland.org/dat/cap/dat.htm
3 Drug Misuse and Dependence - Guidelines on Clinical Management (1999), Department of Health ( UK wide)