This letter authorises the extended use of the following guidance until 1st June 2019:

Transcription

1 NHS Grampian Westholme Woodend Hospital Queens Road ABERDEEN AB15 6LS NHS Grampian Date: 13Th November 2018 Our Ref: FA_ONS_Guide/MGPG/Nov18 Enquiries to: Frances Adamson Extension: Direct Line: tadamsonamhs.net Dear Colleague This letter authorises the extended use of the following guidance until 1st June 2019: Guidance For The Prescribing Of Oral Nutritional Supplements In Substance Misuse Patients Within Primary Care In NHS Grampian Due to current change within the service in regard to Oral Nutritional Supplement supply the above guidance has been is extended for use until 1st June If you have any queries regarding this please do not hesitate to contact the Pharmacy and Medicines Directorate. Yours sincerely Lesley Thomson Chair of the Medicines Guidelines and Policies Group

2 ...,,,... NHS Grampian Guidance For The Prescribing Of Oral Nutritional Supplements In Substance Misuse Patients Within Primary Care In NHS Grampian Co-ordinators: Dietetic Prescribing Advisor, NHS Grampian Consultation Group: Substance Misuse Team, NHS Grampian Substance Misuse Dietitian Advanced Clinical Dietitians, Gastroenterology Approver: Medicine Guidelines and Policies Group Signature: Ga. Nat Signature: Identifier: NHSG/Policy/ONS_SMS/ MGPG852 Review Date: November 2018 Date Approved: November 2016 Uncontrolled when printed Version 3 Executive Sign-Off This document has been endorsed by the Director of Pharmacy and Medicines Management Signature:

3 This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) or (01224) This controlled document shall not be copied in part or whole without the express permission of the author or the author s representative. Title: Unique Identifier: Guidance For The Prescribing Of Oral Nutritional Supplements In Substance Misuse Patients Within Primary Care In NHS Grampian NHSG/Policy/ONS_SMS/MGPG852 Replaces: NHSG/Pol/ONS_SMS/MGPG638, Version 2 Lead Author/Co-ordinator: Subject (as per document registration categories): Key word(s): Process Document: Policy, Protocol, Procedure or Guideline Document application: Purpose/description: Group/Individual responsible for this document: Policy statement: Dietetic Prescribing Advisor, NHS Grampian Prescribing Policy Substance misuse, alcohol, malnutrition, under nutrition, oral nutritional supplements, sip feeds, food fortification, MUST screening tool Policy Medical, nursing and dietetic staff in NHS Grampian To provide medical, nursing and dietetic staff with guidance on appropriate prescribing of oral nutritional supplements in substance misuse clients Dietetic Prescribing Advisor It is the responsibility of all staff to ensure that they are working to the most up to date and relevant policies, protocols procedures. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/Policy/ONS_SMS/MGPG852 - i -

4 Responsibilities for ensuring registration of this document on the NHS Grampian Information/ Document Silo: Lead Author/Co-ordinator: Dietetic Prescribing Advisor, NHS Grampian Physical location of the original of this document: Job title of creator of this document: Job/group title of those who have control over this document: Pharmacy and Medicines Directorate Dietetic Prescribing Advisor, NHS Grampian Dietetic Prescribing Advisor, NHS Grampian Substance Misuse Dietitian, Royal Cornhill Hospital Advanced Clinical Dietitians, Gastroenterology, ARI Responsibilities for disseminating document as per distribution list: Lead Author/Co-ordinator: Dietetic Prescribing Advisor, NHS Grampian Responsibilities for implementation: Organisational: Sector Departmental: Area: Review frequency and date of next review: Operational Management Team and Chief Executive General Managers, Medical Leads and Nursing Leads Clinical Leads Line Manager This policy will be reviewed in two years or sooner if current treatment recommendations change Responsibilities for review of this document: Lead Author/Co-ordinator: Dietetic Prescribing Advisor, NHS Grampian Revision History: Revision Date August 2016 Previous Revision Date April 2014 Summary of Changes (Descriptive summary of the changes made) Change Complan, Build-Up to Complan (retail), Amyes (retail), Meritene Energis or supermarket own brand. Changes Marked* (Identify page numbers and section heading ) Page 4, First line dietary advice, bullet point 5. * Changes marked should detail the section(s) of the document that have been amended, i.e. page number and section heading. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/Policy/ONS_SMS/MGPG852 - ii -

5 Guidance For The Prescribing Of Oral Nutritional Supplements In Substance Misuse Patients Within Primary Care In NHS Grampian Contents Page No 1. Introduction Objectives Definitions Clinical Situations Patient Groups To Which This Document Applies Patient Groups To Which This Document Does Not Apply Process Document Main Components and Recommendations Nutritional advice will have been given and tried References: Distribution list... 6 Appendices... 6 UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/Policy/ONS_SMS/MGPG

6 Guidance For The Prescribing Of Oral Nutritional Supplements In Substance Misuse Patients Within Primary Care In NHS Grampian 1. Introduction Oral Nutritional Supplement (ONS) prescribing in substance misuse clients continues to be an area of concern, not only because of cost but also the question of appropriateness. These clients may have a range of nutrition related problems such as; Poor appetite and weight loss Nutritionally inadequate diet Constipation } Dental decay } in drug misusers in particular Sore mouth } For a variety of reasons such as; Drugs of misuse, e.g. opioids, can cause poor appetite, reduce ph of saliva leading to dental problems, constipation, craving sweet foods. Chaotic lifestyles. Lack of interest in food and eating. Poor dental hygiene (drug misusers in particular). Irregular eating habits. Lack of support from family and friends. Poor memory. Poor nutrition knowledge and skills. Low income, intensified by increased spending on drugs or alcohol. Homelessness/poor living accommodation. Poor access to food. Infection with HIV or hepatitis B and C. Eating disorders with co-existent substance misuse. Prescribing ONS in this client group may not address the underlying problems such as poor income, lack of knowledge or interest in food and prolonged use may just exacerbate existing problems Objectives To provide medical, nursing and dietetic staff with guidance on appropriate prescribing of oral nutritional supplements in substance misuse clients. To reduce inappropriate use of ONS in this client group. To ensure this client group receives appropriate first line dietary advice. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/Policy/ONS_SMS/MGPG

7 1.2. Definitions Substance misuse refers to any client using illicit drugs or drinking alcohol to excess. ONS refers to: 1.3. Clinical Situations Food intake can be compromised in this client group, however emphasis should be placed on improving diet through use of food rather than prescribed ONS in the first instance Patient Groups To Which This Document Applies Any adult with a diagnosis of substance or alcohol misuse Patient Groups To Which This Document Does Not Apply Children. 2. Process Document Main Components and Recommendations Any clients reporting problems with their diet or weight or requesting ONS should be advised by medical or nursing staff on suitable and practical ways to improve their food intake in the first instance. Box 1 outlines several points to consider when discussing diet and nutrition with this client group. It should be explained that weight loss is usually caused by inadequate food intake, and that the only long term solution to this is to improve eating habits and food intake, which may take a considerable time. It should also be stressed that improving food intake doesn t have to be costly or time consuming. Box 1 - Points to consider when discussing nutrition Why is their appetite poor? Are they still using any illicit drugs or alcohol to excess? Are they constipated? Do they smoke? How much do they smoke? This can reduce appetite. Are they filling up on empty calories such as fizzy drinks, tea, coffee? What is their usual weight? Is there any evidence of weight loss or malnutrition? What do your patients eat? Highlights appropriate resources to use for some of these problems. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/Policy/ONS_SMS/MGPG

8 First line dietary advice Healthy eating is not necessarily appropriate however the Essential Food Groups can be used to discuss the basics of a nutritious, balanced diet. The emphasis for most clients is on increasing high calorie and protein foods. Everyday food and drinks can be enriched with ingredients such as cream, cheese, butter or margarine, skimmed milk powder. The Best weight is Up provides ideas and information on food fortification and high calorie and protein foods. This should be used to re-enforce verbal information. Over the counter products such as Complan (retail), Amyes (retail), Meritene Energis or supermarket own brand should be suggested in the first instance. Patients can also be provided with the NHSG Dietetic resource Food Fortification : A Guide to Adding Extra Nourishment which provides recipes for high energy homemade milks shakes, desserts and snacks. Advice for specific symptoms Nutrition Bundles are available for use with substance misuse clients. These contain a series of dietary information sheets to help deal with specific problems such as constipation, difficulty chewing, poor appetite. Weight should be recorded initially and then again monthly for the next 2 months to assess the effectiveness of dietary advice. If there is no improvement, consider referring to the Community Dietetic Department Aberdeen/Aberdeenshire : Moray Prescribing ONS If ONS are deemed necessary by the GP or another Health Care Professional (HCP), the client should be referred to the community dietetic department before a prescription is issued. Clients should not be referred to Community Dietetic Department simply because they are requesting ONS. Measures to improve food intake should have been discussed and tried first. Clients should be made aware that the Community Dietitian will not always recommend ONS. Where they feel ONS are not necessary alternatives will be recommended. The following must be considered before ONS are prescribed to this client group: 1. The client will have: BMI<18 or MUST (Malnutrition Universal Screening Tool) Score >2 plus evidence of significant weight loss (>10% usual or recent weight). Co-existing medical condition which could affect weight or food intake, e.g. liver disease, hepatitis C. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/Policy/ONS_SMS/MGPG

9 And 2. The client will be: In a rehabilitation programme, e.g. methadone or alcohol detoxification programme, on interferon therapy or on the waiting list to enter a programme. Or Pregnant and failing to gain weight. 3. Nutritional advice will have been given and tried If ONS are initiated; The client should be reviewed monthly. If they fail to attend their review appointment ONS should be stopped. Maximum prescription should be for approximately 600 kcal/day (2 bottles of a standard ONS). They should not be put on a repeat prescription unless attending review by a dietitian. They should be prescribed on a short term basis only (i.e. 1-3 months) in the first instance. If there is no change in weight after 3 months dietary intake will be reassessed and the effectiveness of ONS considered. If weight gain occurs, ONS will be continued until usual weight or healthy weight is reached, and a reduction and eventual cessation of ONS will be negotiated. Hepatitis C Patients with hepatitis C are seen by a dietitian at the Peter Brunt Centre at ARI along with other members of the multi-disciplinary team including Gastroenterologists and Liver Specialist Nurses. It is recognised that the medical therapy for hepatitis C has an adverse effect on appetite and nutritional status 1. Patients can present with a 5-20kg weight loss and frequently require to use ONS due to problems with appetite, nausea and lethargy. Dietetic treatment usually lasts beyond the medical treatment time and the dietitian will discharge patients only when they no longer require ONS. Dietetic treatment lasts 6-12 months on average. Policy and procedure for General Practitioners and Primary Care Staff for managing malnutrition and prescribing oral nutritional supplements in adults provides further information about prescribing of dietary products or alternatively please contact Grampian Dietetic Prescribing Advisor ( ). 4. References: 1) Hamer, C. (2008) The impact of combination therapy with peginterferon alfa- 2a and ribavirin on the energy intake and body weight of adult hepatitis C patients. Journal of Human Nutrition and Dietetics 21 (5) UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/Policy/ONS_SMS/MGPG

10 5. Distribution list General Practitioners throughout NHS Grampian Substance Misuse Leads for dissemination to substance misuse teams Lead nurses for dissemination to community nurses (district nurses, health visitors, nurse prescribers) Director of Pharmacy and Medicines Management for dissemination to lead and primary care pharmacists Lead dietitians for dissemination to NHS Grampian Dietitians Appendices Nutrition and Dietetic Contacts Aberdeen City* Aberdeenshire* Moray ARI Royal Cornhill Hospital Community Therapy Services Links Resource Centre Park Road City Hospital Community Dietetic Department Aberdeen Community Health & Care Village 50 Frederick Street Aberdeen AB24 5HY Department of Nutrition and Dietetics Dr Gray s Hospital Elgin Moray Specialist GI/Surgical dietitian Dietetic Department Rosehill House Aberdeen Royal Infirmary Dietetic Department Royal Cornhill Hospital Aberdeen Tel: Tel: (internal Ext 45577) Tel: Tel: Tel: *Referrals for clients in Aberdeen City and Aberdeenshire should be sent to the Health and care Village, Aberdeen. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/Policy/ONS_SMS/MGPG