Would it be fair to discontinue scripting for clients whom for whatever reason does not attend for keyworking sessions? I know keyworking enhances the treatment given to client's, but personal I don't believe this is something that can be enforced upon clients even if they originally signed a document highlighting this as part of their scripting.

I think patients need to be seeing someone, the way we work is that the patient gets the prescription at the appointment, following prescriptions are posted. If someone is stable they can attend every 4-6 weeks and I don't think that is too big a burden.

I agree with Simon. I would like to add however that it depends what a keyowrking session entails. As Simon says (sorry about the reference to an awful song)they need to be seeing someone because its a controlled class A drug we are talking about here, but if they do not have other issues that they need or want to address at that time the keyworking session should be tailored accordingly. Linking it to the script is usually the most effective way of ensuring attendance and is the most convenient for all concerned.

I kind of agree with the above, but have to say that many primary care patients have been in treatment for some time and may not want/need the formal keyworking as a matter of routine in order to get their script. The patient however needs to see the person prescribing the meds though, at least to discuss their progress etc. There are many reasons why people want to opt out of being 'keyworked' and this should be explored. Discharging people for not wanting keyworking is not good practice.

Key working is such a catch all term as to be for the most part meaningless.From a cosy chat,to in deepth work on "issues",it can be all things to all people.
In a lot of cases I imagine they are treatment reviews and would benefit from being called this.Key working conjures up the notion that the "expert" holds a key which can unlock the problems (or have I been reading too much Harry Potter).
The new TOP form might serve to shed much needed light on this cloaked activity.In short I agree that individuals need to be seen at intervals jointly agreed by all parties.Far too many people are seen too frequently, meeting the Key workers needs rather than the patients.They (the patients) need to be walking the walk not talking the talk.

It is very dangerous to "discontinue" a script, and should be avoided.

It is common sense, but also confirmed by the research, that unplanned discontinuation of a script leads to increased death rate, infection rate, crime rate, social/family chaos, and deterioration in all the indicators that are used to justify the benefits of maintenace prescribing.

Clearly if I am the prescriber, i need to see the person to review their health and the efficacy of the script, (guidelines say at least every 3months) .

There are lots of ways to ensure somone is seen, even if they are not good appointment keepers. Ultimately if I am worried about their health and safety, I can stand at the surgery door holding the script until they turn up, and have a look at them before handing it over, or loiter around in the pharmacy. (though I've never felt the need to go so far)

In primary care in Birmingham we have a sytsem which I have described on this site before, of "NAAF" patients. It stands for "Non-Active-Active File". This is for people who do not need, or sometimes just do not want, any active "drugworking" (with all that might encompass) at the present time. The prescriber (usually GP) sees the person at least every 3 months for medication review,(I usually see them at least every 6 weeks, asa can't be bothered to write scripts for longer, and I like to say a quick hello when I hand them over) and the drugworker sees them at least twice a year, to do a "care plan" which confirms the they are still happy with the service and the script and not wanting or needing any other support at present.They also tick all the NDTMS boxes.

If things change at any time (and they often do) the file is still open and the person can be "unNAAFed" instantly without having to go through any reassessment process.

all generally works pretty well.

Tshepo.. i would be surprised if a "document" signed at the start of treatment were used to decide what was needed further down the line. Peoples lives change and Care Plan reviews can reflect changes hopefully.

Judith,
I like the NAAF idea and wonder whether we could be brave enough to do this, but it does make sense. The longest we leave patients withoutbeing seen is 4-6 weeks max. if they are stable. The NAAF idea goes along the normalising treatment and would be what anyone else with a chronic condition would be doing.
I'll ponder this more as something at the back of my mind is telling me it's not a good idea for us.

Hi
There is one healthcare professional that they HAVE to see... the Pharmacist, if you can get a dialogue going with them , I am sure they will be helpful, even if it is 'they are the same they have always been', they are putting on weight(could it be an alcohol belly, or good health)they are looking unhealthy,but we are not sure why(no money/drug misuse). For some it can be a real life saver if pointed out, please ring the Pharmacist to find out what is going on..

Claire,
You are right the pharmacists role in my opinion is definitely under utilised. This couldbe key to reducing peoples apointments in clinic. Wonder how this will look when more pharmacists are prescribing.

So the pharmacist has been checking out my beer belly when I get my prepartion H.I thought I was getting a lot of attention.

quote:

Originally posted by Perseverance:
So the pharmacist has been checking out my beer belly when I get my prepartion H.I thought I was getting a lot of attention.

Next time you might have an LFT and a digital rectal examination.

At last a chance to use the privacy area!

I am laughing at this - but seriously .......
I am wondering if Tshepo's clients who do not want keywork are monitored somehow to ensure risks are not increasing - otherwise how does a prescriber know what risks/ benefits they are balancing ?
We certainly wouldn't stop a script for non - attendance, but after attempts at contact and talking to pharmacist, we would perhaps leave a note with the next script and hold the following one at the CDT ( or surgery ) handing it over having ( as Judith says ) whilst casting eyes on the client. Also I think it is useful to have some review of care plan once in a while. Peoples lives do change, sometimes dramatically. Time period for this ? not sure, we work on attendance and known stability , and if a client is a non attender without good reason ( e.g. working, other illness or commitments ) for over 2 months we would make efforts to contact the person ( or other professionals involved ) & find out more. Otherwise how can prescribers of controlled drugs justify their actions ?

Being a service user rep I've come across quite alot of clinents who don't want to see a key worker for one reason or another, but the fear of their scipt being stopted means they don't take the risk. Not all clinent will get on with the keyworker, & some just don't like seeing them they feel safer seeing their persciber espacail if they are perscibed injectables. At present Prewich is going though some changes and are going back to the way they were at the verry beging and all clinents are going back to their CDT. most are realy reluctent to do this because of not having the security of the hospital on and if any problems arise, time will tell but with all treatments most have a condision attached and if that to see a key worker and you don;t feel that not the best for you , then you can always ask to see your persciber before your next review and try to exspain why you feel the keywrorker dose not work for you. and if there is anyone else who you could see without having your scipt stopted, if its only the once youve missed then scipts should not be stopted untill the keyworker or someone have contacted you to see why you didn;t attend.

I no sometimes its not always clear and at that time most don't realy want to know the reason why a scipt is discontinud but its the 3 day rule if a client has not pick up a scipt for 3 days the guide lines are that they must be reassed because of risk,and their dose may need to looked at again both increased & decreased. its not because the keyworker is just plain differcult but its also to cut the risk down & cover their own back it could be many reasons why they have not pick up and it easy to just take it for granted that your bodie will need that dose but it could be that you need more or less and by stoping the scipt you get reassed, and any changes can be made, in this day of law suites one needs to whatch their own back has well has the clients.

We have a very low discharge rate in Cumbria, but also a problem with DNA's. I don't feel I can continue to prescribe if I don't see patients on methadone or buprenorphine. If they aren't eseing the keyworkers either, then I am down to a very dubious safety net of the pharmacists - who may or may not have some training & knowledge. (No offense to pharmacists, but the degree of support seems very variable). If patients go beyond what is reasonable in the way of supervison/monitoring, then I feel actions have to be taken. Stopping the scrip is the last resort, but when all else has been tried, it seems to me this may be the only action that will force a client to attend their appt.
What does every one else do, when 6 months since you last saw the client (as in a consultation, not just collecting a script), the keyworker hasn't seen them for 3 months, you don't know what they are taking on top of their script, they have ignored all requests to attend, or cancelled at the last minute (effectively same thing)?
Rob

Rob,
As I previously mentioned we issue the script at a consultation so patients DNA less. We post other scripts out for up to 6 weeks. Each GP or Nurse is responsible for issuing the scripts until the next appt. If pt's don't attend they don't have a script - so they come.

The new guideliines have a relvent message for this debate, and that is because of the very new emphasis (whole of chapter 4 devoted to it) on what is being termed as psychosocial interventions' - its what we normally think of as keyworking. The message is that keyworking or PSI is a CORE element of treatment, not an add on. After all for many drug users, pescribing is not appropriate anyway, but also the evidence shows that keyworking can be an effective intervention in its own right. (thiat depends on how well its being done, but that is another subject.)
So the reason to insist on it is that it is part of the treatment, as well as for safety considerations. And as Tommneville says, the sorting out whatever problems there are in client keyworker relationship makes sense. Seems preferabler to letting a bad situation drift on, getting the prescribing without the keyworking is only accessing half the treatment.

hmmm . Yes but.. getting nothing at all can't be preferabler to anything can it?

I am a natural rebel, but like to use the Guidelines to back me up wehn I can. I remind everyone that "the Guidelines say" that people must have a "prescriber's" review (I nearly said "medical") of the medication at least every 13 weeks and start to refuse to sign scripts if I can see someone has not been seen at 12 weeks.

They must then have spot-lights shone on them until they turn up ..eg daily pickup instead of weekly pickup (with messages written on the blue script to ask the pharmacist on duty to remind patient of day and time of appt) That usually brings people hopping down.

Sometimes , when they eventually appear it is obvious that in fact all is well, and they did not feel a need to be seen, in which case I appeal to them to help us the next time by appearing on time to reassure us of their excellent state of health, and not to waste our time needlessly worrying about them when others need more help.

Many times the people who are not turning up are the very ones who in fact do need more psycho-social assistance , and they have been too chaotic come and get it. So once they appear the work can begin.

I imagine in Ulverston, people have travel long distances, and if they have good solid lives, with no psychosocial problems, and just need the opiate script, then you have to insist that the price they pay for the script is to humour you by turning up every 3 months for review. Not a lot to ask, and cheaper than heroin. It is almost never necessary to actually stop the script (for longer than 24 hours) but keeping chasing people in this way is of course very time consuming, and if in fact they are doing very well, i try to make them feel very ashamed for wasting everyone's time when i eventually get to see them. However i think we just do have to take the time to shine the spot-lights until people turn up. Stopping the script altogether cuts off the light.

Judith, your approach seems to suggest "keyworking" as a dispensable optional extra for those that want it only - is that correct, or am I mis-interpreting?

Simon - if your patients DNA, do they not get a script? If so, when do they next get a script?

Susi, I totally agree that keyworking is a fundamental part of working with substance misuse, & that prescribing is only part of the treatment. However, not all the patients agree with that! It can be difficult to engage some beyond their script.
Rob