Idara CNC Library

Substances at a glance

1 · Assess first

• Substance, route, amount, frequency and last use
• Past severe withdrawal, seizure, delirium or overdose
• Other sedatives, medicines, medical and mental health risks
• Observations, mental state, pregnancy, supports and safe setting

2 · Red flags — escalate

• Reduced consciousness, slow breathing or overdose
• Seizure, delirium or severe / rapidly worsening withdrawal
• Chest pain, severe agitation, psychosis or suicidal intent
• Unstable observations, pregnancy complications or unsafe setting

3 · Withdrawal: A‑P‑M‑T‑C

Assess risk → Place safely → Monitor → Treat to plan → Continue care. Alcohol, benzodiazepine and GHB withdrawal may be dangerous. Withdrawal is one stage, not the whole treatment plan.

4 · OAT made simple

• Methadone — full agonist; strong craving/withdrawal control; accumulation and sedation risk
• Sublingual buprenorphine — partial agonist; lower overdose risk; may precipitate withdrawal if started too early
• LAIB — weekly/monthly injection; never invent catch-up dosing

5 · Missed OAT doses

6 · Treatment options

Harm reduction and naloxone · OAT · planned withdrawal · counselling · relapse-prevention medicines · rehabilitation · peer, family and social support.

Substance guide

Withdrawal management — five steps

• Assess — pattern, last use, previous severe withdrawal, polysubstance, health, pregnancy, supports, risk
• Choose the setting — low risk may suit outpatient; severe past withdrawal, unstable health or poor supports may need specialist, residential or inpatient care
• Monitor — observations, mental state, hydration, nutrition, withdrawal tools (a score supports judgement, never replaces it)
• Treat safely — supportive care and guideline-based medication within policy, scope and prescriber direction
• Plan what comes next — counselling, OAT, relapse prevention, rehab, GP care, peer support, harm reduction

OAT: the W.I.S.E. dose check

• Withdrawal — symptoms before the next dose may mean inadequate coverage
• Intoxication — sedation, slurred speech or impaired coordination means stop and assess, never automatically dose
• Substance use & safety — alcohol, benzodiazepines, other opioids, interactions, overdose risk
• Effect & experience — cravings, side effects, goals, adherence, missed doses, function

Ongoing OAT care

Regular clinical and treatment-plan reviews · psychosocial support offered, never used as punishment · physical and mental health care · urine screening only when clinically indicated and explained · naloxone and overdose education · safe storage and takeaway risk assessment · clear transfer, hospital and missed-dose communication.

Options by treatment goal

Everything in the One-Page Quick Reference and the Drug Health Basics Cheat Sheet in one printable document, with two additions:

Dose numbers — staff learning only

Missed LAIB appointment

LAIB timing depends on the product, last injection, dose, symptoms and clinical circumstances. Do not invent a catch-up dose — check the current LAIB guideline / product instructions and obtain prescriber advice.

Missed-dose restart examples (NSW guidance)

After 4–5 missed days, only the prescriber may authorise a reduced restart — examples given: buprenorphine half the usual dose or 8 mg; methadone half the usual dose or 40 mg, followed by gradual return.

1 · NSW Treatment of Opioid Dependence (2018)

• Comprehensive opioid, polysubstance, physical, mental health and psychosocial assessment; match intensity and setting to complexity
• OAT with methadone or buprenorphine; withdrawal management with linkage to continuing treatment; psychosocial care, harm reduction, naloxone
• Safety: never dose an intoxicated patient; missed doses require review (tolerance can fall, overdose risk rises); transfers and takeaways need documented risk assessment

2 · Management of Withdrawal from Alcohol & Other Drugs (2022)

• Withdrawal is a stage, not the endpoint — the plan continues into relapse prevention, AOD treatment, primary care and psychosocial support
• Choose the setting by risk: outpatient for lower risk; specialist, residential or inpatient for severe past withdrawal, unstable health, poor supports or complex polysubstance use
• Alcohol care includes preventing Wernicke’s encephalopathy and monitoring for seizure or delirium

3 · Treatment of Alcohol Problems, 4th ed (2021)

• Screen quantity, frequency, standard drinks, heavy-use pattern, dependence and consequences
• Brief intervention and motivational approaches; planned withdrawal matched to risk; psychological treatment and long-term follow-up
• Relapse-prevention medicines: naltrexone or acamprosate when suitable; disulfiram reserved for selected patients
• Whole-person care: liver disease, nutrition, cognition, sleep, mood; support reduction or abstinence per patient goals

4 · Long-Acting Injectable Buprenorphine (NSW Health, 2024)

• Current Australian products: weekly or monthly Buvidal, monthly Sublocade
• Benefits: no daily supervised dosing, stable exposure, convenience, reduced diversion risk
• Before commencing: confirm dependence, tolerance, recent opioid use, goals; review sedatives, pregnancy, previous buprenorphine response
• Ongoing: trained administration only; monitor withdrawal, cravings, sedation, injection sites; plan missed injections, transfers, hospital care in advance; provide naloxone

Common practice across all four

• Person-centred, culturally safe and trauma-informed engagement
• Assess the person, not only the substance — physical, mental, social, safeguarding
• Match treatment and setting to risk, complexity, goals and supports
• Combine medication with psychosocial care, harm reduction and follow-up
• Closed-loop communication — ensure the receiving clinician accepts the plan

A structured template covering the full assessment in eleven sections:

Closed-loop confirmation block

Receiver and service · date/time/method · agreed actions and care owner · repeat-back confirmed · documented in eMR · patient/carer informed.

Worked example 1 — missed methadone doses

GP referral after six consecutive missed methadone doses → intake arranges same-day prescriber review; GP continues interim monitoring with ED/000 advice if deterioration; same-day escalation timeframe, repeat-back confirmed.

Worked example 2 — alcohol withdrawal

Adult with alcohol dependence, ~1 bottle of spirits daily, previous withdrawal seizure (2024), liver disease, poor intake for two days. Developing withdrawal — tremor, sweating, tachycardia, rising withdrawal score. Recommendation: urgent medical review, authorised withdrawal plan, frequent observations, hydration + thiamine/Wernicke prevention, immediate escalation for seizure, confusion, reduced consciousness or CERS criteria.

Identical structure to the printable shared care template (see that card for the full outline), with fillable PDF fields so it can be completed on screen during a call or case conference and saved per client.

• Header block: patient, MRN/DOB, review period, lead clinician, GP/practice, Drug Health clinician, pharmacy, consent/sharing limits, interpreter and cultural needs, patient goal
• Shared-care team grid: provider, role in care, contact, information shared/consent, preferred communication
• Then the five model sections — comprehensive assessment, care planning, risk management, progress monitoring, transfer of care

Purpose: coordinated shared care between the patient, GP, Drug Health, pharmacy and other providers — completed collaboratively, in respectful person-centred language, and updated whenever treatment, risk or responsibilities change.

Structure

• Header: the whole care team, consent and sharing limits, patient goal, primary substances, after-hours / urgent / emergency arrangements
• 1 · Comprehensive assessment — twelve domains (presenting concern & goals, substance history, withdrawal, overdose & reduced tolerance, OAT medicines, physical health, mental health & suicide risk, injecting/BBV/sexual health, housing & safeguarding, cultural & communication needs, legal & practical, strengths & previous treatment response), each with findings / risks / actions columns
• Clinical formulation: main problem, severity, drivers, protective factors, priority risks
• 2 · Care planning — goals, responsibilities, review points
• 3 · Risk management — named risks with owners and escalation
• 4 · Progress monitoring — outcome measures and review schedule
• 5 · Transfer of care — handover plan and re-entry pathway

Referral flowchart

• 1. Identify AOD concern → 2. Screen urgency (overdose, severe withdrawal, seizure, delirium, chest pain, psychosis, suicidality? → urgent: 000/ED)
• 3. Define the request — assessment | withdrawal planning | counselling | OTP/LAIB | medication advice | harm reduction | shared care | stable OTP transfer
• 4. Refer to WSLHD Drug Health Central Intake (02) 9840 3355 with consent, substance/last-use history, withdrawal and overdose risks, medicines/OTP, reason and requested action
• 5. Close the loop — confirm receipt, document interim care owner, safety-net advice, follow up, ISBAR for handover

Medication comparison (summary)

The ABC of Drug Health care

Assess · Build goals · Counselling · Detox safely · Evidence-based medicines · Follow up · Give harm reduction (naloxone, no sedative mixing, sterile equipment, BBV testing, driving advice) · High risk: escalate.

Who can be supported

• Adults 18+ with hazardous substance use or a substance use disorder
• Existing Drug Health clients transitioning to primary care; stable OTP clients suitable for community management
• Priority groups: Aboriginal people, CALD communities, refugees, people experiencing homelessness, co-occurring mental illness, socioeconomic disadvantage

What the liaison function does

Specialist advice and case discussion · referral navigation and coordinated shared-care planning · GP, pharmacy, Mental Health and community-service liaison · support for alcohol, opioids/OTP, LAIB, stimulants, benzodiazepines, withdrawal and harm reduction · GP education and capacity building.

Not suitable / redirect

• Immediate medical or psychiatric emergency → 000 or ED
• Likely severe or complicated withdrawal → urgent clinical assessment
• Needs acute inpatient care or intensive case management
• Outside catchment → relevant LHD intake or ADIS

Minimum referral information

• Patient identifiers, contact details and consent
• Substances, route, amount, frequency, last use
• Withdrawal, overdose, seizure or delirium history
• Current medicines, OTP/LAIB dose, prescriber and pharmacy
• Medical, mental health, pregnancy and psychosocial risks
• Reason for referral and requested assistance
• Interpreter, cultural and accessibility needs

Safe handover: ISBAR, then document advice, agreed responsibilities, timeframe, follow-up and the escalation / re-entry plan.

“You can ask for help at any stage.” Treatment can reduce harm, help you stop or cut down, manage cravings, avoid overdose and reconnect with what matters.

Options explained

What to expect

Respectful, non-judgmental care · choices in plain language · a plan made with you, not for you · support for physical and mental health · interpreter and culturally safe support where available.

Eight role areas

Specialist access (advice pathway, call log, response standard) · Care coordination (verified-GP process, annual summaries) · Practice engagement (practice map, visit schedule) · Education (OTP, stigma, trauma-informed care, front-desk module) · Shared-care design (tiered model, minimum dataset, ISBAR, role matrix) · Quality improvement (baseline audit, PDSA, dashboard) · Stigma reduction (practice checklist, safe-space signalling) · Sustainability (coverage model, SOP, succession — nothing depends on one person).

Which practices to target

• Priority 1 — existing patient GPs: verify with patients, start where GPs already care for multiple OTP patients, check consent, offer support not a prescribing request
• Priority 2 — AOD-friendly practices: previous OTP/AOD experience; mental illness, chronic pain, hep C, homelessness or justice cohorts; Aboriginal, refugee, LGBTQ+ or youth health; near Blacktown, Mount Druitt, Parramatta, Westmead and dosing points
• Priority 3 — WentWest/PHN channels: engagement leads, practice-development officers, education events, newsletters, HealthPathways, practice champions

Context

WentWest (the Western Sydney PHN) reports 336 GP clinics in its region; its AOD priorities match the project’s populations — Aboriginal people, mental-health comorbidity, CALD communities, older people, people leaving prison, LGBTQIA+ people, homelessness, young people.

Practice selection criteria (rate Low / Medium / High)

Existing relationship · patient access · clinical capacity · team capacity · attitude & safety · communication · population fit · readiness · sustainability.

First 90 days

Includes ready question lists for WentWest (contacts, privacy approvals, education channels, HealthPathways updates) and for each practice (current OTP patients, barriers, preferred communication, named contacts, sustainability).

Contains the full WentWest Engagement Plan plus these working sections:

Measures to track from the start

• Patients with a verified GP and documented consent
• Practices contacted → engaged → actively participating
• Training completion (GP, nurse, reception)
• Advice request type/volume; median response time and % within target
• Referral completeness and annual-summary delivery
• Primary-care appointments, care plans, preventive health
• Patient-reported stigma, access and continuity
• Incidents or treatment gaps linked to communication
• Rapid re-entry requests and outcomes
• GP prescribing interest or transfers — a secondary, longer-term outcome

Opening scripts

Immediate next steps

• Confirm terminology and get the approved project protocol, role description and engagement boundaries from Tracy and the manager
• Request a meeting with the WentWest AOD / integrated-care lead
• Audit verified GP details for a small OTP patient sample; identify five practices already caring for multiple OTP patients
• Prepare a short GP needs-assessment survey
• Define the rapid-advice coverage and escalation model before advertising the phone number
• Prepare the annual-summary minimum dataset and consent process; pilot small rather than approaching all practices at once

Ends with a GP/practice engagement tracker (practice, suburb, contact, existing OTP patients, interest, needs, next action, date) and note-capture pages.

Her contribution: the clinical and operational bridge — what information must be exchanged, who communicates it, when, how urgent concerns escalate, and how transfer is confirmed and monitored.

Essential OTP transfer information

• Consent and current contact details
• OAT medicine, formulation, verified dose and authority arrangements
• Last supervised dose, dosing point, takeaways supplied/remaining
• Missed doses, recent intoxication, withdrawal, overdose, non-prescribed use
• Treatment history, goals, planned dose changes
• Physical/mental health, pregnancy, allergies, other medicines
• Current risks: sedatives, child safety, homelessness, self-harm, cognition
• Prescriber, pharmacy and Drug Health contacts — who to call when problems arise
• Interim plan, next appointment, care owner, escalation / re-entry pathway

Regulatory and safety points

• A receiving prescriber must agree to accept care before transfer completes; the current prescriber supplies the clinical information
• A patient must be exited from one prescriber’s OTP authority before another is authorised; permanent dosing-point changes notified through the NSW process
• SafeScript NSW manages OTP authorities and dosing-point information
• No automatic dosing of an intoxicated or markedly sedated patient
• Transfers must never create a gap in treatment, prescription coverage or pharmacy supply

The role sits inside a grant-funded research project (≈ 2–2.5 years remaining) with academic co-investigators, ethics oversight and measured outcomes.

The three real goals

• Communication — GPs want “your phone number”: an answer on the spot or a callback within 15–30 minutes, and a known person to call when something goes wrong
• Care coordination returned to general practice — the GP coordinating overall care, as for every other condition; Drug Health clients currently miss out because they present directly
• Stigma reduction — better GP–Drug Health communication is the mechanism that breaks the barrier

What the project delivers to practices

Front-desk stigma / trauma-informed care training · methadone & buprenorphine information for GPs (no ask to prescribe) · patient resources — chronic condition management plan pathway, “ask 3 questions” shared decision-making, Aboriginal health governance (≈20% of clients Aboriginal) and LGBTQ+ safe-space signalling · annual patient summaries pushed to each client’s GP.

The KPI tension — and the fix

Also from the call: the GP recorded in eMR is frequently wrong — verify with the patient and log it; the missing shared-care model is an authorship opportunity; Tracy offers her networks (two GP contacts doing this transition work) and active support for the role’s success.

Data dictionary to sign off in month one

• “OTP transition” = care coordination transfer (prescribing reported separately)
• “50 shared care clients” — cumulative new per year, or concurrent caseload?
• Can one contact count toward multiple KPIs where it genuinely is both?
• Education sessions include all five MOC formats (clinical update, practice visit, online training, case conference, CPD)

Six things win permanency

• KPI attainment with trajectory — monthly run-rate vs target as a trend, never a year-end surprise
• Cost-offset story — each OTP client moved to GP care frees a public dosing place; community management avoids ED presentations. Dollars and capacity are the language of a business case
• Demand exceeding capacity — referral volumes, practices engaged vs total, waiting-time creep
• Equity outcomes — Aboriginal and CALD engagement vs baseline headline every report; they justify the funding
• Stakeholder voice — GP testimonials, WentWest endorsement, AMS partnership, Tracy’s written support
• Governance cleanliness — CRM attendance, ISBAR handovers, no scope breaches

The ten operating directives

• Log every contact the same day
• Friday data hour — 60 protected minutes to reconcile the tracker
• One education session per month, locked a quarter ahead
• Survey after every closed episode and every session
• Report monthly without being asked
• Stay in scope — no case management, NDIS or housing; log redirects as demand evidence
• Escalate by the book — MO/senior clinician per pathway, ISBAR every handover
• Collect the story: one de-identified vignette per month
• Month six: open the business case file
• Protect the equity narrative — Aboriginal/CALD figures lead every report

Then the standing rhythm: advice line as the flagship service, site visits to the programs already doing GP transitions, and the shared-care model draft on Tracy’s desk by month three.

Practice introduction email

Referral accepted

Referral not accepted

Every non-acceptance still gets logged — it is documented demand.

Education invitation

The 30-second pitch

Taking an advice call — the intake questions

• Frame: GP, practice, callback number; patient-specific or general? “What would be most useful by the end of this call?”
• Substance picture: which substance(s), amount/frequency/route/duration, last use; previous treatment; withdrawal history — ever seizures, DTs or admission?
• Whole patient: age, pregnancy, mental health and suicidality, comorbidities and medicines (esp. sedatives), children in care, driving, what the patient actually wants

Closing the call — Ask, Offer, Ask

Summarise back (“so we have a… is that right?”) → offer, anchored to a named guideline (“under the NSW guidance this looks suitable for… how does that sit with you?”) → safety-net + next step (“if [red flag] happens call me straight back; I’ll email a summary today”). Then eMR note + tracker row, same day.

Case conference in 15 minutes

1 min patient/consent/purpose · 3 min progress (attendance, doses, screens, goals) · 3 min risks and changes · 5 min decisions needed today · 3 min agreed plan — who does what by when, next review. Confirm any treatment change to the GP in writing the same day.

Transfer-of-care letter (ISBAR)

The document that makes or breaks a transition — a GP who receives one complete handover takes a second patient. Sections: I introduction + consent · S what is transferring and why · B diagnosis, treatment episode, current medicine/dose/last dose, comorbidities · A stability evidence (months at stable dose, attendance, screens, takeaway status, psychosocial) · R scripts interval, pharmacy briefed, review frequency, early-warning signs, and the guaranteed return pathway: one phone call, no new referral. Close with the 2-week check-in call — which is itself a logged GP consult.

GPs are persuaded by evidence, ease and a safety net — in that order — never by pressure. Method: Ask what concerns them → Offer the evidence anchored to a named guideline → Ask what they think. A GP argued into a treatment abandons it; a GP who chose it defends it.

Objections and responses

The four treatment pitches (frame + guideline + support offer)

• OTP transfer to GP care: “This patient has done the hard part — what they need now is a normal doctor for a normal life. Staying in a clinic they no longer need holds them back and holds a place someone else is waiting for.” (NSW Opioid Dependence 2018; full handover, briefed pharmacy, 2-week call, guaranteed return)
• LAIB: “One injection replaces the daily pharmacy visit — for someone who works, that’s the difference between staying in treatment and dropping out.” (NSW LAIB 2024; switch coordinated, first administration supported)
• Alcohol pharmacotherapy: “PBS-listed medicines GPs can prescribe that meaningfully cut relapse — dramatically under-used. Patients who’d accept a tablet from you will never walk into a drug and alcohol clinic.” (naltrexone, acamprosate; withdrawal planning through us first if any seizure/DT history)
• Take-home naloxone: “The seatbelt conversation of opioid care — free, no prescription, reverses an overdose while the ambulance comes. Offering it isn’t an accusation, it’s standard practice.”

Verify dose- and eligibility-level detail with the Medical Officer before leaning on it in conversation.

Monthly report to manager (one page)

KPI table — target / this month / YTD / % of annual / status — plus: practices engaged (n of total), highlight (one vignette or GP quote), risks and barriers (one line + what’s needed), next month focus. The tracker workbook prints this automatically.

Quarterly executive report structure

1 service snapshot · 2 KPI dashboard · 3 equity outcomes vs baseline · 4 system impact (OTP places freed, ED avoidance, GP capability) · 5 stakeholder feedback · 6 governance (CRM participation, incidents) · 7 risks and asks · 8 next quarter priorities.

GP satisfaction micro-survey (5 items, 2 minutes)

• The advice/support was timely (5-point)
• The advice was clinically useful and practical
• My confidence managing AOD presentations has improved
• I would use the service again and recommend it
• What could we improve? (free text)

Satisfied = agree/strongly agree on usefulness or would-recommend. Send after every closed episode, every education session, and quarterly to active GP contacts.

Business case for permanency — skeleton (open at month 6)

• Purpose: convert the CNC1 position to recurrent funding · Strategic alignment (WSLHD plan, equity priorities, NSW AOD standards, Aboriginal Health Plan)
• Demonstrated performance (KPI trajectory) · Demand (referrals, practices engaged/waiting)
• System benefit (OTP places × value, ED avoidance, GP capability) · Equity impact vs baseline
• Stakeholder endorsement (GP testimonials, WentWest letter, Tracy, AMS) · Consequence of discontinuation
• Cost: 1.0 FTE + on-costs vs quantified offsets · Recommendation and decision sought

One workbook, one habit: add a row the same day, and everything else calculates itself.