Self‐reported and observed heroin overdoses in Malmoe

In the addiction field, the approach to the client is being discussed because the care that is offered is apparently not fully effective, efficient or of sufficient quality. In the Netherlands the new policy direction in the addiction field aims at improving the quality and innovation of care and prevention by use of evidence‐based research. One of the spearheads is ‘Social Addiction Policy’, which focuses on material context (housing, work, etc.) and social circumstances in which addicts live. This paper outlines the concept of demand‐driven care and discusses its applicability in the addiction field. Quotations from drug users and clients of various services are used to illustrate the issues and attitudes discussed in the article. The new policy in the addiction field encompasses so called ‘assertive outreach’, which implies that care providers actively try to reach those marginalized groups that do not seek help themselves. Although this seems to be in contradiction with the general concept of demand‐driven care, it is argued that demand‐driven care in the form of assertive outreach is both necessary and possible. Four main characteristics of the addiction field are discussed in relation to the principles of demand‐driven care, and are compared with characteristics of the healthcare sector. A demand‐driven approach seems to be worth the effort, also in the addiction field.     

Enhancing the quality of nursing care in methadone substitute clinics using action research: a process evaluation

Title. Enhancing the quality of nursing care in methadone substitute clinics using action research: a process evaluation Aim. This paper is a report of a study to answer the research question: can participative action research help to halt the deterioration in methadone substitution treatment and develop new care strategies which are better geared toward the patients’ needs? Background. In the Netherlands, methadone substitute treatment has been the main medical treatment for heroin addiction since the early 1980s. Although effective at first, this methadone provision has deteriorated during the last 15 years. Over time, nursing staff have had to restrict their activities to simply dispensing methadone and have not been able to develop any other interventions, such as outreach care. Method. A participative action research process was used in two outpatient methadone substitute treatment clinics. Using the four stages of the cooperative inquiry design of Heron and the knowledge development model of Johns, a diagnosis of all the bottlenecks was made and innovative care strategies were implemented. Reflection meetings were held to offer nursing staff maximum benefit in improving the quality of nursing care. Findings. Action research partially succeeded in enhancing care strategies. Of the two clinics involved in the study, one improved both its care organization and patient‐centred outcome. The other managed to improve the organization of the care. Conclusion. Participative strategies can be, but are not always, a helpful method for enhancing professional care in addictions nursing. By setting out attainable goals in daily practice, some nurses were able to become active change agents. The development of knowledge is inextricably connected with the growth of new care strategies. Chronic opiate users can benefit from the expansion of professional nursing knowledge.     

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence,in Collaboration With the Heart Rhythm Society

Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline development process, the American Pain Society commissioned a systematic review of various aspects related to safety of methadone. After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone. Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps, most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence.PerspectiveThis guideline, based on a systematic review of the evidence on methadone safety, provides recommendations developed by a multidisciplinary expert panel. Safe use of methadone requires clinical skills and knowledge in use of methadone to mitigate potential risks, including serious risks related to risk of overdose and cardiac arrhythmias.     

Resource allocation for community-based therapy

PURPOSE: Adequate and equitable resourcing of services for children with disabilities and their families is a challenge that is faced by agencies as the growth in client numbers outstrips any increase in available funding. While funding models have been developed within the acute health care and education sectors, there have been few attempts to develop funding models for therapy (occupational therapy, physiotherapy, psychology, and speech pathology) provided within community-based, paediatric disability services. This paper outlines a model for allocating staff resources to provide therapy services for children with physical disabilities based on a project conducted by Novita Children's Services (formerly the Crippled Children's Association of South Australia, Inc.). METHOD: Services were mapped using a framework based on the International Classification of Function developed by the World Health Organization and adopted by the Australian Institute of Health and Welfare. An action research methodology was employed that included focus groups held with staff to identify potential resource drivers; collection of travel time data, client caseload numbers; and developing profiles of services and client groups. A model for allocating staff time was developed to reflect the differing service demands, travel time, leave allowances and time for activities to develop the social environment for individuals with disabilities. RESULTS AND CONCLUSIONS: Analysis indicated that the drivers of staff resources were the type of service delivery (early intervention versus school aged services), model specific (e.g., time required to provide community-based services and work within multi-disciplinary teams), and specific client (need for complex technology or equipment; school/preschool transition times; high health care needs due to dysphagia, deteriorating conditions with changing needs, or post surgery/medication rehabilitation) and family well-being issues. While further data collection and refinement of the model is needed, it provides the organization with more objective and equitable resource allocation and enables improved advocacy for client needs.     

4 years' methadone substitution therapy in Austria]

On September 25th 1987 methadone was legalized for therapeutic use in Austria. During the past four years altogether 1828 opiate addicts were admitted to methadone maintenance treatment. 439 females and 926 males were currently being treated in December 1991; their age ranged from 16-59 years, the daily oral d,l methadone dose levels varied between 10 mg and 250 mg per day. Only 406 doctors and 123 pharmacies participate in methadone maintenance treatment, which does not provide complete cover for the area in spite of increased finding. Moreover, the doctors' skills in this treatment have to be improved by requisite training. As Austrian experience shows, methadone treatment offers a first step towards social rehabilitation for drug addicts who have been living as criminals on the fringe of society. Socioeconomic data, as well as criminal behaviour changed dramatically for the better due to this treatment in Austria. Physicians have a clear responsibility to lead the effort on all fronts in the implementation of this treatment modality. Therapeutic drug monitoring should become routine in methadone treatment to ensure compliance and to achieve optimum results, especially in patients who complain of withdrawal symptoms and continue high-risk behaviour and to increase acceptance of substitution therapy. The Austrian treatment model for methadone maintenance treatment is a positive example for other countries who wish to introduce this treatment modality for drug addiction.     

Resource allocation for community-based therapy

Purpose. Adequate and equitable resourcing of services for children with disabilities and their families is a challenge that is faced by agencies as the growth in client numbers outstrips any increase in available funding. While funding models have been developed within the acute health care and education sectors, there have been few attempts to develop funding models for therapy (occupational therapy, physiotherapy, psychology, and speech pathology) provided within community-based, paediatric disability services. This paper outlines a model for allocating staff resources to provide therapy services for children with physical disabilities based on a project conducted by Novita Children's Services (formerly the Crippled Children's Association of South Australia, Inc.).

Method. Services were mapped using a framework based on the International Classification of Function developed by the World Health Organization and adopted by the Australian Institute of Health and Welfare. An action research methodology was employed that included focus groups held with staff to identify potential resource drivers; collection of travel time data, client caseload numbers; and developing profiles of services and client groups. A model for allocating staff time was developed to reflect the differing service demands, travel time, leave allowances and time for activities to develop the social environment for individuals with disabilities.

Results and conclusions. Analysis indicated that the drivers of staff resources were the type of service delivery (early intervention versus school aged services), model specific (e.g., time required to provide community-based services and work within multi-disciplinary teams), and specific client (need for complex technology or equipment; school/preschool transition times; high health care needs due to dysphagia, deteriorating conditions with changing needs, or post surgery/medication rehabilitation) and family well-being issues. While further data collection and refinement of the model is needed, it provides the organization with more objective and equitable resource allocation and enables improved advocacy for client needs.     

Development of the client-centred care questionnaire

Aim. This paper reports the development and testing of the Client‐Centred Care Questionnaire, aimed at evaluating the client‐centredness of professional home nursing care from a client perspective. Background. Client‐centred care has become an important theme in health care. To evaluate the client‐centredness of care and services from a client's perspective, there is a need for measurement instruments. Method. The questionnaire was developed on the basis of a qualitative study into client perspectives on home nursing care. Items were formulated that closely followed the aspects clients mentioned as central to client‐centred home care. A pilot study was conducted with a sample of 107 clients in three home care organizations in 2003 and 2004. These clients had chronic diseases and were expected to receive care for at least another 6 months. The questionnaire comprises 15 items. Findings. Principal components analysis and internal consistency analysis show strong internal consistency of the items. All items had strong factor loadings on one dimension, and Cronbach's alpha was 0·94. Clients tended to be most critical about their say in the practical arrangements and organization of care: which person came, how often and when? Clients of the three organizations differed in their perceptions of client‐centredness, which may indicate that the questionnaire is capable of differentiating between respondents. Conclusion. The results of this pilot study are promising. The validity of the questionnaire needs further testing.     

Home pediatric nursing care service in Germany--a quantitative study of the status of home pediatric nursing care providers in Germany

In Germany, the importance of pediatric home care has increased consistently over the past 20 years. Nevertheless, compared to adult home care, pediatric home care remains a small part of home care service in general. So far no adequate financing is available in Germany which sufficiently covers the special needs of pediatric patients. This article presents data on facilities for pediatric home care with respect to their personnel and internal structures, as well as services, and types of financing and reimbursement. Likewise, the client structure of these organisations is described with the emphasis on medical diagnoses, age range, and nationality (of the children in pediatric home care). The data gathered are helpful in funding negotiations with the responsible agencies in order to emphasize the particular issues of ill children and their families and with the intention of extending the traditional list of services for home care to include services for children which are otherwise often not paid for by these agencies.     

Theoretical and clinical approaches to the treatment of adolescent drug addiction.

Psychologists, social workers, addiction specialists, and occupational therapists often find themselves faced with clients who not only are addicted but also have personal, family, and social problems. These combined problems make the drug-abusing client an extremely difficult one to work with. Occupational therapists have a particular challenge in that they must not only understand and analyze their clients' occupational behavior but also their needs as addicts. This paper describes an approach to adolescent addiction that presents a clinical and theoretical consideration that could be helpful to professionals who work with addicted or drug-abusing clients. In the approach a fusion must be made between the client and the therapist or treatment program. The fusion is temporary but long enough to provide opportunities for clients to work through their feelings of anger, aggression, and sadism, as well as their ego and superego problems. To understand all aspects of their use of drugs, an easily memorized two-dimensional scheme is drawn by the client and therapist together and is used to formulate a treatment plan. Separation from the therapist or program is an essential part of treatment. At this time the client is given the kind of emotional support required to establish new relationships.     

Client-centred care perceived by clients of two Dutch homecare agencies: a questionnaire survey

BACKGROUND: Client-centred care is currently one of the prevailing principles in Dutch healthcare policy. OBJECTIVE: The purpose of this study was to assess the client-centredness of homecare as evaluated by clients and to explore the relationship between client characteristics and the perceived level of client-centred care. DESIGN: A cross-sectional design was used. SETTING: Two homecare agencies in the Netherlands. PARTICIPANTS: We selected a sample of 732 clients receiving personal care or housekeeping assistance from two homecare agencies in the Netherlands. A total of 323 questionnaires were included in the analyses. METHODS: The client centred care questionnaire (CCCQ) was used to evaluate the extent to which care was patient-centred. RESULTS: The results show that clients were especially positive about the responsiveness of carers to their needs and wishes. Clients thought that carers really listened to them. Clients were relatively negative about opportunities to direct and organise the care themselves, as well as about the timing of care delivery and the lack of continuity of care. Independent sample tests and ANOVA revealed that marital status was the only socio-demographic factor that was statistically significantly related to the perceived level of client-centred care. It was found that married clients evaluated the care as more client-centred than clients who were unmarried, divorced or widowed. CONCLUSIONS: Clients were positive about most aspects of client-centred care. Client-centred care can be further optimised by giving clients more opportunities to direct and organise the care themselves.     

Case management problems and home care.

The author summarizes a review of the case management problems encountered at the Visiting Nurse Service of New York, the largest certified provider of home care services to people with AIDS in the world. Case management problems can be divided into four general categories: client/significant others, housing/community, support services, and nurses' needs. Concrete solutions to these problems are discussed. As the number of people with AIDS increases, more home care agencies and discharge planners will need to consider these issues when planning care in the community.     

Predictors of elder and family caregiver satisfaction with discharge planning

Client satisfaction is considered an important outcome measure in a managed care environment faced with escalating health care costs, shortened lengths of hospital stay, and competition among acute care hospitals. With shortened lengths of stay in acute care hospitals, discharge planning has assumed increased importance, particularly for elders who have chronic conditions, such as heart failure, that require follow-up care. Consequently, understanding the predictors of client satisfaction with discharge planning can help hospitals and their nursing staff to tailor services to meet client needs. Previous studies have focused on patient satisfaction with hospital care, with little attention given specifically to satisfaction with discharge planning and to family caregiver satisfaction with discharge planning. The purpose of this study was to determine whether there is a difference between elder and family member satisfaction with discharge planning 2 weeks after hospitalization and what factors predict satisfaction with discharge planning 2 weeks after hospitalization for elders hospitalized with heart failure and their family caregivers. Telephone interviews were conducted with 134 elder/family caregiver dyads 2 weeks after hospitalization. The results indicated that there were no statistically significant differences in discharge planning satisfaction of elders and their family caregivers. Continuity of care and extent to which they felt prepared to manage care following hospitalization were the best predictors of elder's and family caregiver's satisfaction with discharge planning.     

Information Needs in Home Care: A Review and Analysis

Before prospective payment can be implemented in home care, providers and administrators in home care agencies require information in a variety of areas. This article reviews the literature on several factors likely to influence the market for home care services, including hospital use trends, the response to diagnosis-related groups by home care agencies, proposed reimbursement patterns, patient disease and demographic profiles, and patient needs. Research must be conducted in several areas before prospective payment can be implemented in home care.     

Broadening the partnerships: experiences of working across community agencies

The creation of inter-agency partnerships to deliver mental health services that meet the health and social care needs of service users is now a central strand of UK national policy and a considerable body of literature has developed around the concept of partnership. To date, however, the focus has been on partnerships between the specialist health and social services, or between these services and primary care. In the course of a study aimed at identifying the mental health training needs of a broader range of community agency staff, it became apparent that partnership working was problematic for the majority of agencies. Focus group discussions were carried out with staff from 21 agencies working across five practice contexts. On the basis of the data obtained we describe the extent of inter-agency working and the barriers to its development. The implications for meeting clients' mental health needs are then considered and means suggested for broadening inter-agency working to include a wider range of relevant agencies.     

Nicotine--drug addiction--AIDS. Drug use habits of Vienna addicts]

In Austria it is illegal to sell tobacco to young adolescents. A diverse sample of 358 narcotic addicts was investigated at the Psychiatric University Clinic of Vienna. Data were obtained from on site confidential interviews and a HIV-test was conducted. The individual drug use history was recorded and, interestingly, tobacco addiction was the first stage in starting a drug career. Furthermore, a strong correlation was observed between onset of heroin use and HIV-1 infection. It is concluded that in Austria not only the availability nicotine and alcohol to young adolescents should be prohibited, but also their use should be punishable. Easy access to nicotine as in public restaurants or from automatic distributors, has to be withdrawn. Tobacco advertisements may drive vulnerable young adolescents to early nicotine abuse and this may be followed by addition to other drugs and diseases causing death, including AIDS. Socioeconomic data, as well as the methadone data are presented. 180 out of the 358 patients were on methadone maintenance. Methadone treatment offers a first step toward social rehabilitation for drug addicts who have been living as criminals on the fringe of society. Physicians have a clear responsibility to lead the effort on all fronts against tobacco, especially in view of the HIV epidemic.     

Evaluation of an assertive outreach intervention for problem families: intervention methods and early outcomes

Scand J Caring Sci; 2011; 25; 211–219
Evaluation of an assertive outreach intervention for problem families: intervention methods and early outcomes Families who experience a chronic complex of socio‐economic and psycho‐social problems are hard to reach with mainstream care. Evidence exists that the core of this problem lies in a problematic interaction between this type of family and current systems of care. The adults and children involved have needs in multiple domains, while the care system is fragmented and highlights well‐defined requests for help. To improve access to this target group, an assertive outreach intervention was implemented into the preventive child healthcare system in the Netherlands. Evaluation research was carried out to get a detailed insight into the content of this intervention. Also, early outcomes were examined. Information was gathered by interviews, attending meetings on method development, analysing registration forms and a survey on client satisfaction. Five intervention stages were identified: case finding, making contact, sustaining contact, developing a family plan and linking (arranging for services to be delivered). Practical support was used to build rapport and clear the way to the uptake of follow‐up help. The professionals delivering the intervention need a broad range of competencies to establish a working relation with the families and to link them to care and services. A good care network across professionals from various organisations must exist to provide a variety of linking options. Early outcomes indicate that professionals were able to get in touch with the families within a mean of 13.2 days. Goals of the intervention were mainly practical support (73%), starting new assistance for a child (63%) and starting new assistance for a parent (43%). Linking to care and services was attained in the majority of the cases and parents expressed satisfaction. The findings indicate that the studied intervention is a promising one. Some potent components can be indicated: the outreach approach, practical support, maximising participation of the family and building bridges between the family and (in)formal support and assistance.     

Clients with intellectual disabilities on psychiatric units: care coordination for positive outcomes

The transition from residential facilities to and from the psychiatric hospital setting is difficult for individuals with intellectual disabilities (ID). In the U.S.A., specialized psychiatric units for individuals with ID are uncommon and this population is usually served in generalized services. Nevertheless, providers of mental health services in the U.S.A. receive little training in their specific needs. Best practices call for coordination of plans between psychiatric units and community agencies, multidisciplinary care plans, staff education and comprehensive discharge planning in order to improve outcomes of psychiatric hospitalization. An inner city psychiatric unit in a major academic medical centre and a community agency providing residential care for individuals with ID cooperated to provide a plan of care for a client with ID both for hospitalization and for discharge leading to improved outcomes.     

美沙酮、丁丙诺啡、洛非西定梯度治疗海洛因依赖戒断症状的研究

目的探索美沙酮与丁丙诺啡加洛非西定梯度治疗海洛因依赖戒断症状的疗效。方法将 15 0例海洛因依赖者分为三组 ,每组 5 0例 ,进行为期 12d的戒毒治疗 ,研究组采用美沙酮 (总量 80～ 110mg) ,丁丙诺啡 (总量 0 .6～ 1.5mg)。洛非西定 (总量 1.6mg)治疗。美沙酮组 (对照A组 )采用美沙酮(总量 13 9～ 175mg)口服治疗 ;美沙酮加丁丙诺啡组 (对照B组 ) ,采用美沙酮 (总量 90～ 12 0mg) ,丁丙诺啡 (总量 0 .9～ 2 .3mg)治疗。用统一的评定量表评定治疗结果。结果研究组在控制戒断症状、停药后无反跳现象、脱试率低、成瘾风险性小等方面均优于两个对照组。结论美沙酮加丁丙诺啡加洛非西定梯度治疗海洛因依赖戒断症状效果满意 ,是一种较好的戒毒方法     

Nurse case management program of chronic pain patients treated with methadone.

Methadone treatment in chronic pain patients is still limited owing to misconceptions about addiction, safety, and its unique pharmacokinetic and pharmacodynamic properties. Nevertheless, patients with chronic noncancer pain are frequently treated with methadone at our Pain Centre either as the first opioid of choice, for specific pain conditions, or as a second-line opioid in patients developing tolerance or intractable side effects with other opioids. The aim of this study was to examine whether a nurse case management program of chronic pain patients treated with methadone is feasible and safe in trying to improve patients' care in an ambulatory setting. This program consisted of three phases: initial primary education session, telephone follow-up during methadone titration, and a subsequent maintenance period. The nurse case manager functioned autonomously and when required reported to and consulted the physician. The study included 75 subjects and was done over a nine-month period by completing follow-up questionnaires for every call. Of a total of 194 recorded calls, 41% were unscheduled. Forty-four percent of phone calls resulted in a methadone increase and 11% led to a decrease or cessation of methadone. No patients developed serious morbidity or mortality. Fifty-seven percent of patients were either satisfied or very satisfied with their treatment. A nurse-led case management program of methadone in chronic pain patients can improve patient care in an ambulatory setting.     

EuropASI: A standard in de Sleutel,Belgium

Aims. The introduction of the EuropASI (European version of the Addiction Severity Index) as a standard intake instrument was inspired by four different viewpoints—clinical, registration, research and management—and aimed at implementation in these four areas.

Setting. De Sleutel includes five ambulatory centres and four residential centres in different parts of Flanders in Belgium. In 1998, the EuropASI interview was introduced in de Sleutel as a diagnostic standard admission for residential as well as ambulatory drug‐treatment settings. Today there is a database of about 2500 EuropASIs of unique clients.

Findings and conclusion. Clinically, the introduction of the EuropASI gave a basic guideline for clinical workers to act, measure and orient the client after his first treatment demand. It provided a uniform procedure that guarantees a well‐balanced focus for all life areas traditionally linked with addiction problems. It also became a useful instrument for structuring the clinical team meetings and led to better planning and treatment. The EuropASI could deliver the minimal data set needed for regional, national and European epidemiological data. The extra time spent in making up special data sets for monitoring or registers could be saved. Uniformity in the way data are gathered could guarantee a better quality of the data for registration, and redundancy eliminated. Instead the basics are set for a treatment‐supporting documentation system. The research concentrated around a more scientifically founded understanding of addiction problems, more specificity in client profiles, an ability to compare groups, research in matching treatment to client profiles, and more insight in to necessary knowledge and skills for the clinical teams. From a management perspective, the introduction of a European standard for basic assessment of our clients could start the process of total quality management, in providing an accepted basis in documenting the core business of the treatment centres.