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Opiate addiction is one misuse and dependence disorder for which we have good pharmacological treatments. Both methadone and buprenorphine are effective in withdrawing individuals from opiates via substitution, and their use in maintenance treatment has an excellent track record. Naltrexone may also be efficacious for selected patients. Psychosocial and behavioral treatments play a role too, most often in combination with pharmacological treatments or for patients who do not want pharmacological treatments. This is one subject in which practice varies enormously in different parts of the world. Readers who look at the text closely will notice considerable geographical variation in treatment polices, and it is a tribute to our authors that they have kept this to a minimum in this combined chapter.
Opioid dependence is a chronic disorder characterized by relapse, increased mortality, significant medical morbidity, psychiatric sequelae and impaired social function in the individual. Accompanying these detrimental effects to the dependent individual are costs to their families and society secondary to impaired social and occupational functioning and increased criminal behavior or violence. In recent years there have been considerable gains in our understanding of the neurobiology of opioid dependence and in the development of new pharmacological and behavioral treatments for opioid dependence.
In 1999 there were estimated to be 1 million chronic users of heroin in the United States, or 0.4% (4 per 1000) of the population (Rhodes et al., 2000).
Core features of New Ways of Working include concentrating on service users with complex needs, acting in a consultative role and carrying out interventions that are timely rather than routine. In this service-mapping exercise a retrospective analysis of 150 case notes was performed to evaluate clinical activity in general adult out-patient clinics and to attempt to measure the complexity of the workload.
Analysis of care programme approach (CPA) level revealed that 40% of patients were not on CPA and 16% of patients were on enhanced CPA. Only a third of the sample had a non-medical care coordinator. Absolutely no changes were made to the management plan in around half of the sample. A minority of patients needed to be seen acutely, within a month, or had their appointment brought forward.
Current out-patient activity of consultant teams does not appear to be consistent with New Ways of Working. Psychiatrists will be required to reflect on their roles in out-patient clinics to avoid ‘routine’ appointments and to use their time more efficiently.
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