Table Of Content

“The cheap option is no bites SCAN longer ‘cheap and cheerful’ but can be actively harmful”Page 5 The quarterly newsletter of the Specialist Clinical Addiction Network | Autumn 2009 | Volume 6 Issue 3 ISSN 1744-6112 In this issue ! We lead this issue of SCANbites with an article from Peter Rice looking at how Scotland is blazing the trail with alcohol policy, together with a summary of a new Scottish alcohol needs assessment. John Dunn summarises a new NTA publication Towards Successful Treatment Outcomes (page 8) ! The retendering debate continues with responses to the findings of the recent SCAN survey from nurses by Jim Jones, Chair of ANSA (page 4) and André Geel, Chair of the Addiction Faculty of the BPS (page 5). Clearly we are not alone! ! The At your service series continues with Mike Kelleher describing the development of Scotland takes action on alcohol addiction treatment in Brixton Prison (page 12), while Sue Ruben tells us how she survived the transition from addiction Peter Rice psychiatry to general adult psychiatry (page 6). The new clinical conundrum series is launched In April 2009 Kenny MacAskill, the alcohol, across all age groups, is closely with three views on how to manage a Scottish Cabinet Secretary for Justice, related to low cost and ready availability, and complex spoke at the Royal College of that the major problem area is the forensic Psychiatrists Addictions Faculty supermarket sector. problem – meeting in Edinburgh and no one who In March, Christine Grahame MSP, featuring the heard him will be in any doubt that the convenor of the Parliament’s Health and observations of Scottish Government means business in Sport Committee and a convert to action on an addiction doing something about alcohol problems. price, said, “I have great concern for the psychiatrist, a What currently distinguishes the hidden numbers behind the net curtains of forensic Scottish approach is that in addition to ideas Scotland, who are putting alcohol in their psychiatrist and on consensus issues such as public supermarket trolleys on buy-one-get-one- a MAPPA education, product labelling and tackling free promotions when they would not coordinator alcohol-related crime, the Government has normally buy it; because alcohol is within (page 10). What happened in Brixton? invested a considerable amount of money, easy reach, they are taking it in the way that £125m, in prevention and treatment, with an they used to drink a cup of tea at night.” emphasis on brief interventions, as well as The 10-15% increase in alcohol-related ! Caroline Cooper reviews expanding specialist services to cope with acute hospital admissions in the over-50s a new book “Community the considerable unmet need. over the past five years suggest she is right treatment of drug misuse” and that action is needed which affects the by Nick Seivewright (page What has prompted this? behaviour of the whole population. This 7), and Aideen O’Kane reflects on the recent What has really stirred things up, though, challenges the comfortable consensus that SCAN conference for have been the proposals to change the the concerns are only with younger people trainees and new availability of alcohol, in particular, the price. and those with an obvious alcohol problem consultants (page 14). The Government has accepted the analysis and the task is to “tackle” these groups and that the chronic health harm caused by leave “the sensible majority”undisturbed. " www.scan.uk.net SCOTTISH STRATEGY " Minimum pricing minimum pricing. The Scottish Treatment access in Scotland So what is the proposed action on Licensed Trade Association, whose price? The medical profession, members are typically owner- including addiction psychiatrists, operated pubs who pride themselves have had quite a bit to do with this. on high standards of practice, have In 2007, Scottish Health Action on supported the policy since its Alcohol Problems (SHAAP), a group inception. Others such as the British established by the Medical Royal Innkeepers Institute and the Colleges in Scotland, produced a Campaign for Real Ale (CAMRA) report on price which called for a have overcome their initial “we don’t minimum price for alcohol. This want more regulation” response and recommendation was based on: now support the measure. There has been the recent support of Tennents, ! A review of the considerable Scotland’s leading lager brand, and Scotland’s population has better access to evidence base on the Molson Coors, the makers of Carling, alcohol treatment than England’s, in spite relationship between price and to explore minimum pricing as a of a higher prevalence of alcohol harm. means of ending deep discounting. ! Evidence that the other most Producers have become increasingly dThepe efnirdste nnaceti onnoartl ha locof hthoel nbeoerddes ra. ssessment commonly used price control public about their resentment of the for Scotland, published in August 2009, mechanism, excise duties, were power of the supermarkets in found an alcohol dependence prevalence no longer effective in the UK as imposing low wholesale prices and of 4.9% in adults, compared with 3.6% in producers and retailers absorbed using alcohol as a loss leader to get England.1,2The study was commissioned these costs. ! E vidence that the price that customers into their stores, where by the Scottish Association of Alcohol and they make their profit on other goods. Drug Action Teams and funded by the mattered most was that of the Scottish Government. cheapest alcohol, so action on The Alcohol Bill: watch this space Overall, 1 in 12 Scots with alcohol the “floor price” was more important than at the expensive All these political and business dependence gained access to treatment in end of the market. battles might seem remote from the 2006/07 compared with 1 in 18 in England ! A legal opinion that, contrary to interests of the average practitioner in in 2004: a 48% higher level of access in what the alcohol industry had the field, but price is the most Scotland. This is likely to be accounted for been saying for years, a important factor in determining what by the 50% higher spend on alcohol minimum price policy may not alcohol-related harm comes through treatment in Scotland: £296 per breach competition law in the the doors of our clinics and hospitals. dependent drinker in Scotland compared UK or European Union because The Scottish Parliament will vote on to £197 in England. Governments were entitled to an Alcohol Bill, including the As this data was collected before act to protect public health. minimum price proposals in the publication of the new Scottish alcohol strategy and the related new investment autumn. We have a minority in alcohol treatment services, this situation Since that report, further work has Government and nothing is certain, is likely to improve further. Welcoming the emerged from Petra Meier and but the health voice has been report, Dr Michael Farrell, Chair of the colleagues from the University of important in the debate so far and RCPsych Addiction Faculty said, “Scotland Sheffield, available on the those of us involved plan that it will has shown the way within the United Dr Peter Rice, Department of Health website, remain so. Kingdom and in Europe with innovative, Consultant which supports the SHAAP evidence-based approaches to prevention Addiction conclusions. The Chief Medical FURTHER READING and treatment of alcohol problems. Other Psychiatrist, Officer in England, Prof Liam Governments would do well to follow a Tayside Alcohol Donaldson, followed the Scottish Scottish Government (2009) Changing similar approach.” Problems lead when he called for minimum Scotland’s Relationship with Alcohol: A Service, Primary pricing in his Annual Report in March Framework for Action.Scottish Care Division 2009. Government, Edinburgh. REFERENCES NHS Tayside, 1 Drummond, C., Deluca, P., Oyefeso, A., Rome, Sunnyside The industry response Drummond, C., Deluca, P., Oyefeso, A., A., Scrafton, S., Rice, P. (2009) Scottish Royal Hospital, There has been a quick response Rome, A., Scrafton, S., Rice, P. (2009) Scottish Alcohol Needs Assessment.Institute of Hillside, Psychiatry, King's College London: London Montrose, from some parts of the alcohol Alcohol Needs Assessment.Institute of (www.saadatonline.co.uk/word_docs/Scottish Angus industry to this work. The Scotch Psychiatry, King's College London: London %20Alcohol%20Needs%20Assessment.pdf) Whisky Association has led the 2 Drummond, C., Oyefeso, N., Phillips, T., charge against minimum pricing in Scottish Health Action on Alcohol Problems Cheeta, S., Deluca, P. et al (2005) Alcohol Scotland and SAB Miller (formerly (2007)Alcohol: Price, Policy and Public Needs Assessment Research Project (ANARP). South African Brewers) Health.SHAAP, Edinburgh. shaap.org.uk The 2004 national alcohol needs assessment commissioned a report to counter the for England.Department of Health: London (www.dh.gov.uk/en/Publicationsandstatistics/ University of Sheffield findings. Information and Statistics Division (2009) Publications/PublicationsPolicyAndGuidance/ Other parts of the alcohol Alcohol Statistics Scotland 2009.Scottish DH_4122341) industry have been supportive of Government, Edinburgh. alcoholinformation.isdscotland.org 2| Supporting specialists, promoting consensus Comment We are not alone! Colin Drummond In the last issue of SCANbites we can it be, for example, that the local needs highlighted the growing concerns of are deemed to be so divergent across nine addiction psychiatrists about the adverse adjacent London boroughs that the clinical impact of increasing retendering of NHS psychology provision varies by a factor of 7, addiction services across England. Since from 0.2WTE in one borough to 1.4WTE then Starship SCAN has boldly gone to in another? other parts of the addiction Universe to explore the views of other specialists in the In yet another galaxy the BMA News field. And clearly we are not alone. highlights similar concerns about the wider NHS in which “finances are being Jim Jones, Chair of the Association of prioritised over care, there is falling Nurses in Substance Abuse, highlights in investment in research and training, and an this issue the concerns of specialist nurses emphasis on profits.”1In their view the in the field (page 4). The same concerns “marketisation” of the NHS, with contracts about disruption to patient care, damage to moving to the independent sector, will staff morale, and replacement of trained have lasting damage on quality of care and specialist staff by people with less workforce training for many years to come. experience and qualifications are shared by Medical training, both for undergraduates nursing colleagues. and postgraduates, appears to have little or no place within new independent sector For those nurses who remain in services contracts or ethos. after re-tendering their continuing professional development is often not So, far from being a problem uniquely financially supported and some nurses re- affecting addiction psychiatry, politically employed under TUPE within 3rd sector driven changes in commissioning practice organisations report being financially worse are raising remarkably similar concerns off. However, their main concern is about a across professions in addictions and the financially driven agenda prioritising wider NHS. As these changes are quantity over quality. Similar concerns are undermining NTA and Department of also highlighted in a consultant nurse’s Health policy, as highlighted by Dr Geel, it letter to SCANbites in this issue (page16). is time for these organisations to formally examine the impact of commissioning Meanwhile in the clinical psychology solar activity on the quality of care and system Dr André Geel, Chair of the British professional training in England. Psychological Society Faculty of Addictions, raises concerns about the The contributions from different future quality of psychological professions in this and the last issue of interventions (page 5). In an environment SCANbites highlight that we share the where clinical psychology leadership is not NTA’s and Department of Health’s vision being appropriately prioritised, he is of the need to improve the quality of concerned not just that psychological addiction treatment. However, this is therapies may be ineffective and at odds unlikely to be achieved in an environment with NTA and NICE guidance, they may where these aspirations are afforded such a potentially be harmful in the wrong hands. low priority at a local level. It may be Dr Geel also highlights what has become a addiction treatment, Jim, but not as we postcode lottery due to differences in know it... nor, indeed as good as it could commissioning priorities for specialist be. professional staffing. Clearly this issue goes beyond the narrower concerns about re- Professor Colin Drummond is SCAN Lead tendering, raising questions about the wisdom of a policy which allows, or even REFERENCE encourages, such wide diversity in 1. Anonymous (2009) Medics rally to anti- commissioning of service provision. How market campaign. BMA News, August 29. SCANbites, Autumn 2009 | 3 RE-TENDERING Specialist nursing observations on the SCAN retendering survey Jim Jones ANSA members report similar informed, political elements. This can nurses with a specialist addiction experiences to those outlined in the include pressure groups with particular background. Of course their position as agendas, and evidence-based treatment commissioners means their skills are lost SCAN survey of addiction principles can suffer. It seems there is to clinical practice, and their skills as psychiatrists. The process of little understanding of what nurses can commissioners are variable due to lack of recommissioning should be one of do; their knowledge, skills and specific training for that role. experience acquired during a 3-year Nurses who have worked in the improving effectiveness, but has all undergraduate professional training may NHS can be TUPE’d across to the new Jim Jones is Chair of the the hallmarks of being cost-driven, make them more difficult to manage; but provider. However, this can lead to Association of with little understanding shown in drug workers with lesser ability or problems with NHS pensions if it is to a Nurses in many cases by commissioners of the professional qualifications are in many 3rd Sector provider, and risks becoming a Substance cases being deployed in services to take ‘gap in service’ if a move back to the Abuse (ANSA). nature of the work being done, or of on the same role at the same salary. For NHS is part of further career the nature of nurses’ roles within it. medical staff it means they will not be in development. The re-commissioning receipt of the support nurses can give to process can result in a cost saving of 20% The process is certainly disruptive, with their role, whilst drug workers often because the new pension arrangements services that cannot see what that support may need are much cheaper for the employer. have lost to be, nor have the ability to provide it. This, of course, may be part of a much contracts RMN trained nurses in particular report bigger financial agenda. running down poor recognition of what they can offer in The concept of “World Class in the months the care of complex service users. Commissioning” has much to offer in Florence before the new Service-users are, of course, worse-off as terms of revitalising service provision Nightingale ones take over, a result. and avoiding complacency. (Although and with little Prison-based nurses report that the the “World” seems limited to the UK in effective handover complex nature of that work is not the manner in which it operates.) occurring. Staff leave recognised by the commissioning However, the devil is in the detail, when faced with an process and new contractual and the detail often means a dumbing uncertain future, the good arrangements are aspirational to the down, cost-driven exercise where ones find work in neighbouring areas point of being pie-in-the sky in terms of professional standards are paid only lip- that have ‘new’ services starting up, the likelihood that goals will be met. service. It must not be forgotten by those leaving behind understaffed services The lack of recognised standards of us who work in the field clinically, that with low morale to trickle on with and qualifications for the role of our client group are not always held in unfilled (and unfillable) posts. Service- commissioner means that nurses have the highest esteem and that in the eyes users do not know how they will found themselves having to defend of outsiders we can be contaminated by continue to be treated after the change accepted professional-practice standards that association. High quality, more until the last minute, and many well- as part of the contracting process. Job costly services for those who some may established therapeutic alliances have descriptions are pared to the bone, regard as ‘criminal deviants’ will not been broken by the particularly the requirement for clinical score heavily with the electorate. On the recommissioning process. supervision and continuing professional other hand the commissioning process Nurses report that many development, which in many instances is needs to recognise that professional commissioners have no left completely financially unsupported nurses who choose to work with this background in drug treatment, within new service contracts. This client group are not attracted by the sometimes no background in emphasises the short-term nature of same things that exist in other areas of health or social care, and are many contracts, with little chance to health care, and that it would be all too dependent on others for grow mature teams, or develop well easy to drive them away into more guidance. This leaves them trained and supported staff. popular, better recognised fields of open to influence from ill- Commissioners do include some practice. 4| Supporting specialists, promoting consensus READY TO BE FIRED? The clinical psychology perspective André Geel The recent SCAN survey raises some better as quickly as possible by consultant psychologists to those who very interesting issues – both threats receiving appropriate and effective are less skilled and experienced. and opportunities, and pros and cons. treatment. However, in my It seems pertinent to all professions, experience this has not always been Indeed, it would be clinically effective but I will respond from the the case. to have a consultant psychologist in perspective of clinical psychology and post in a borough, who would then my own clinical experience in some In my current post, I am in the supervise psychologists, key workers, London boroughs. fortunate position to be able to nurses, and CBT therapists in Dr André Geel, observe both directly and indirectly, psychosocial interventions, as opposed Cluster Lead There are very few Clinical the functioning of both general and to counsellors using eclectic (a Consultant Psychologists working in the psychology-specific addiction services mixture of humanistic, Clinical addictions field. They number in nine London boroughs. I also psychodynamic and other) Psychologist, somewhere between 100 and 200 directly supervise the psychologists in interventions which are not evidence- CNWL Foundation spread across the United Kingdom. four of those boroughs. It is clear that based, and which are indeed clinically Trust, London, and As a profession they represent the the way that psychology services in ineffective, counter-therapeutic and Chair of the “Psychology of Addiction” – the these different boroughs are contra-indicated. (See page 14 of Faculty of behavioural, cognitive, interpersonal commissioned varies hugely. Across Psychosocial Interventions for Drug Addictions, British and non-medical, non-chemical/non- the nine boroughs, consultant Misuse, 2009.) Psychological pharmacological view of the addictive psychologist posts range from 0.2 Society process. Within their teams, services WTE (whole time equivalent) to 1.4 The cheap option is no longer “cheap and organisations they are ideally WTE and other psychology posts from and cheerful” but can be actively positioned to be standard bearers and 0.0 WTE to 4.0 WTE. harmful. Based on the above champions for the psychosocial evidence it is possible that some interventions so comprehensively The value that commissioners place services that are commissioned purely highlighted by NICE and others in on quality appears to vary greatly and on a low budget may actually be the last few years. there appears, in some cases, to be making patients worse, when if a little little awareness of the need for high more money was spent more carefully, With the publication of the NTA’s quality such as, for example, the service could be designed to make “Psychosocial Interventions for Drug consultant psychologist posts as a patients better. Misuse” in 2009 we now have three consistent need. Much of the more consecutive years of guidelines and recent commissioning discussions The Hippocratic Oath of “do no literature attesting to the need for focus on cost and are not quality- harm” applies equally to the “professionalism”: the Darzi report, driven. There appears to be very little psychosocial interventions, and we “High Quality Care for All” in 2008 awareness or acknowledgement of should ensure that we design services and for “clinicians to inform strategy, NICE, NTA or Department of Health in a way that includes a quality control and drive quality, service design and guidelines. In some local boroughs element, which will in turn ensure resource utilization” from the services appear to have been clinical effectiveness. The least one Department of Health’s “World Class commissioned on their cost alone and could do would be to have a Commissioning” in 2007. From this, not on whether they were NICE or consultant psychologist as lead the message seems clear and the NTA-compliant. It is my experience clinician for psychosocial interventions evidence overwhelming that that a number of non-NHS providers, in each service. This would ensure commissioners must commission who are not required to have that the workforce is appropriately services that ensure that patients get consultant-level or chartered trained and supervised, and that psychologists as part of their staff patients are seeing the right therapist complement, have been using the right intervention. commissioned to provide psychosocial interventions without being We have now reached a point in the NICE/NTA compliant, or without development of psychological commissioners placing NICE/NTA- compliance as a requirement for a treatment where we know which successful bid. treatment works for which disorder and with which patient. We need to I do believe that it is possible to commission an affordable service and ensure that our workforce reflects for it still to be NICE/NTA- this knowledge and does not compliant, but it takes some time to continue to repeat old mistakes. design such a service as the details involve looking at skill mix, workforce Commissioners need to use this redesign, key worker and drug worker knowledge constructively and competencies, as well as requirements intelligently as part of their for supervision and training, and the required ratios of experienced, commissioning process. Ivan Pavlov SCANbites, Autumn 2009 | 5 LIFE AND POETRY appreciation of the subtle and complex interplay between mental illness and substance misuse. All posts have service development opportunities, and negotiation skills are well developed when coming from addiction, to say nothing of our finely tuned Confession bullshit detectors! There are, of course, differences. I’m addicted New teams with strange names To now exist. There were a few Addiction medications I had never prescribed, (in a healthy way of course) but surprisingly few in fact and easy Life after addiction psychiatry to learn. I hadn't been to a Mental I crave Health Review Tribunal for years The and I found the first few tough. My (or how to return to the adult Chaos ever sharp tongue got me through. Stories world and survive it) I am glad I kept up Section 12 Variety Approval and stayed on the on-call Stimulation rota. It was surprisingly easy to get Frustration stuck into a new job with a Even perhaps the NTA Sue Ruben different patient group and new (Well let’s not get carried My career plan, not that I'd have helpless and made a decision to challenges. My sense of humour away) called it that, was to stay in return to adult psychiatry rather than returned. Liverpool Drug Services until await my fate. A job was available I did grieve. I couldn't drive past I retirement or death. With the with colleagues I knew and liked in my old office without crying, Dream relentless move to the cheap and Wales, and it was commutable from necessitating a change of route to Of cheerful "no frills services" (or Liverpool. my new job – red eyes are so A relapse Back "Easydrug" as I called them), The move back to the adult world unattractive in a woman of my age. To drugs and alcohol addiction psychiatrists were to me, was daunting. I managed it while To this day I have a ridiculous gripe an endangered species surrounded keeping a foot firmly in the that irks me. I didn't get my Friends sigh by predators replacing full-time addiction world. Here are some picture in "Trust Matters" when I You look Consultants with sessional GPs. thoughts which may help others left – the only Consultant ever not So well The day in early 2005 when I who have to make a change and for to be so honoured. Now that I work Rested uncovered the plan to dispense with trainees who aspire to addiction but in Adult Psychiatry I do not forget Happy my post was a strange one. I where no suitable post is available. my first love, Addiction. And I am realised too late that, having The skills required to be a I have negotiated a personal relinquished my role as Clinical Consultant Psychiatrist are largely development plan allowing time for But it’s always there Director, I had lost any semblance of transferable across sub-specialities. addiction courses and conferences. An insistent influence over any aspect of local We have a lengthy training and I offer second opinion work for the Nagging services including my own. I was a background in mental disorders local addiction services. I volunteer Little voice dinosaur facing extinction. within a broad based socio-bio- for groups that are relevant to my In My popularity with colleagues and special expertise. I teach on The back of TRANSFERABLE SKILLS service users meant nothing as I did addiction topics within mental My head not have the support of the Trust's psychological model. Our strength health services locally, and on the executive team, local should be in bringing leadership Liverpool MRCPsych Course. I Be warned commissioners, or the NTA. The qualities and a real understanding am involved in an alcohol research It’s with you For life letter I had written expressing my and commitment to multi- group in North Wales with a concerns on matters of clinical disciplinary working. funded project underway. I hope governance had won me no friends A background in addiction gives us My final advice is to make the best in the organisation, nor had my fairly much experience in working across of whatever job you do and it will extensive knowledge of the traditional boundaries. We are used be interesting. I would return to literature and evidence base, which to forming therapeutic relationships my first love if an opportunity arose seemed to irritate rather than with hard to engage patients – my but, if not, I will continue to enjoy educate. personal favourites. Adult the adult world, my new colleagues "I feel like a character in a Kafka psychiatry teams often find and the privileges that a career in Dr Sue Ruben, novel," I said to the manager, who substance misuse issues hard to psychiatry has brought me. consultant in was unmoved and merely informed tackle, despite the high prevalence I finish with a short confessional general adult me that he had never heard of Kafka within their populations. They poem which I recently wrote on the psychiatry, North Wales NHSA Trust so couldn't comment. I felt ill and welcome expertise and an train to Bath. 6| Supporting specialists, promoting consensus BOOK REVIEW detail and illustrated with case histories, work is barely mentioned and service with shorter sections touching on commissioning is not discussed at all. methamphetamine, khat, cyclizine, The book gives the impression that most hallucinogens, steroids and solvents. drug treatment services are placed within Cannabis, alcohol and nicotine are discussed the NHS – hopefully by the publication of only in relation to their implications for drug the 3rd edition, this will still be the case. A services, without addressing the chapter is devoted to drug treatment in management of patients with problematic primary care, and another to dual diagnosis use of these substances alone. and the overlap between drug use and Case histories are scattered throughout mental disorder (including personality the book, and bring the text to life. disorders). Although I’m sure there was a temptation to It could have been written with me in mind use positive examples of how treatment brought about marked changes in the The final chapter before the appendix patient’s circumstances, (“patients” or (protocols for various detoxification regimes substance “misusers” throughout, rather for heroin) looks at liaison work and special than clients or service users), many examples patient groups: work within general show less-than-good outcomes, which hospitals and prisons, with pregnant reflect the realities of providing treatment women, adolescents, and older patients for our particularly challenging group of who are at greater risk of physical health patients. problems. Physical issues such as pain and The book does not shy away from blood-borne viruses are also reviewed with controversies of drug treatment in the respect to their impact on addiction services. community: the fact that in prescribing we The book could have been written with replace one addictive substance with me in mind – it is a more readable guide to Community treatment of another, or that patients abstinent from one practice than the orange guidelines, and I substance may start using an alternative; would certainly recommend it as a valuable drug misuse: More than difficulties in defining success of treatment companion for psychiatrists starting out in (psychosocial stability versus abstinence, the this field, for drug workers to understand methadone Nick Seivewright, current recovery agenda conflicting with the more about the medications we use and assisted by Mark Parry need to retain patients in treatment); the why, and to GPs working in addiction (who role of treating individuals to benefit wider may not have had the opportunity to Review by Caroline Cooper society; and enforced treatment as a experience as full a range of psychological potential alternative to custodial sentences and supportive interventions as those with a in the criminal justice setting. psychiatry background). The difficulties in providing treatment to Unfortunately, it is limited in providing Many will be familiar with Nick people living in socially deprived areas with information on pharmacological and Seivewright’s original book on occasionally questionable motivation to biological mechanisms (although the 25 the community treatment of change are also referred to. pages of references at the end provide a drug misuse, and its beguiling Following the introduction to sound starting point for those wanting to sub-title “More than methadone”, which he community treatment of addiction and a read up on this material), and it may lack originally chose to encourage services to review of methadone, associated treatment the detail desired by more experienced incorporate psychological approaches to aspects are examined – counselling, clinicians. However, they too may benefit treating opiate misuse and to offer treatment contracts and drug testing, and from a book which provides thought- treatment for drugs such as cocaine for safe prescribing. Different pharmacological provoking opportunities to re-examine which there is no substitute prescription. approaches to opiate detoxification are theoretical and practical aspects of their Originally published in 2000, when the covered, followed by strategies for work. use of buprenorphine was in its infancy and preventing subsequent relapse. Strengths LAAM was still prescribeable, this has been and weaknesses of other opiate substitute !Seivewright, N. (2009) Community updated with a second edition providing an drugs (in particular buprenorphine) are Treatment of Drug Misuse: More than updated resource whilst remaining true to discussed, as are prescription amphetamines methadone, 2nd Ed. Cambridge University the original aim: to provide practical advice and benzodiazepines, although the lack of Press, Cambridge. based on scientific evidence. mention of modafinil as a potential Dr Seivewright is assisted by Dr Mark substitute treatment for stimulant use may Parry in providing a more comprehensive, age this edition of the book. updated literature review alongside practical The second section of the book information. This focuses on opiates, but addresses service provision: the also includes the effects, complications and development of community drug services Dr Caroline Cooper, SCAN treatment of other substances of abuse. Of and the organisation of teams, but Trainee and specialist registrar, these, cocaine, amphetamine, ecstasy and unfortunately the increasing role of non- Nottingham Healthcare Trust benzodiazepine misuse are covered in most statutory drug services in providing Tier 2 SCANbites Autumn 2009 | 7 NTA Towards successful outcomes Preventing unplanned discharges from drug treatment services John Dunn The NTA has developed guidance for services in England. Seventy eight percent who dropped out of treatment may no longer service providers and commissioners on entering drug treatment were retained in need treatment. good practice in preventing unplanned treatment for at least 12 weeks and a further 4% In 2007/08 69,642 individuals were discharges from drug treatment services: had a planned discharge before 12 weeks. discharged from treatment of which 51% Towards successful treatment completion – a Whilst successfully retaining clients in successfully completed treatment and were said good practice guide.1This article summarises treatment for 12 weeks or more is an important to have had a planned discharge. However, 48% the main areas that the guidance covers. proxy for the delivery of effective strategies to had an unplanned discharge, with treatment engage and retain clients in treatment, it does drop out being the commonest reason (28%). Background not always translate into clients subsequently There has been a downward trend in The document examines the reasons why successfully completing their treatment and unplanned discharges from 71% of individuals clients may not complete drug treatment and leaving treatment services in a planned way. leaving drug treatment in 2004/05, to 66% in examines factors involved in successful planned If a client chooses to leave treatment in an 2005/06, 58% in 2006/07 and 48% in 2007/08, discharges; reviews the research on measures unplanned way, often before their goals have which adds credence to the potential for designed to improve engagement and retention been fully achieved, or if treatment is optimising further the number of planned in treatment; and gives examples of good clinical withdrawn, the client can be said to have had an discharges that can be achieved. practice aimed at improving treatment unplanned discharge. Whilst not all do badly effectiveness and successful treatment after such a discharge, it is generally considered The profile of unplanned discharges outcomes. By engaging and retaining clients in good practice to maximise planned discharges. There is considerable variation between effective treatment, it is anticipated that more Unplanned discharges occur for a range of partnerships in the rate of unplanned discharges. will achieve their treatment goals and leave drug reasons, the commonest being dropping out of Data from the National Drug Treatment treatment in a planned way. treatment, followed by going to prison, Monitoring Service (NDTMS) and the Drug The development of the guide was treatment being withdrawn, the client declining Interventions Record (DIR) are presented in the supported by an expert advisory group the treatment offered or moving away and losing good practice guide. The analysis shows that established for this purpose, and was finalised by contact with the treatment service. ‘service factors’ have a much bigger impact on its agreement. The group included An unplanned discharge does not treatment outcome than client characteristics. representatives from addiction psychiatry, necessarily mean that treatment was a failure. However, drug(s) of misuse also has an impact, primary care, research, addiction nursing, For example, clients who are discharged because in particular combined opiate and crack use pharmacists, NHS treatment providers, the non- they have gone to prison should have their increases the risk of having an unplanned statutory sector and client advocacy groups. treatment continued under the Integrated Drug discharge. Other important themes identified in For 2007/08, 202,666 individuals were Treatment Systems (IDTS) that have been the analysis include: some stimulant users being recorded as being in contact with drug treatment introduced in the prison estate. Some clients unable to access treatment services, problems in 8| Supporting specialists, promoting consensus setbacks – clients may relapse or increase their no sign of progress or when there is evidence of levels of illicit drug use or fail to reach the goals deterioration in treatment. Withdrawing set with keyworkers. Helping clients develop treatment that involves substitute opioid strategies to deal with these challenges is an prescribing puts clients at significant risk of essential aspect of clinical care. relapse back into illicit heroin use and is This section of the good practice guide associated with increased risk of drug-related discusses the evidence that inflexible treatment overdose death – 20 times higher than that of packages, punitive responses to continued illicit clients who stay in treatment involving drug use and a poor therapeutic alliance militate prescribed opioids.4Therefore, a balance needs against clients staying in treatment. Clients who to be struck between protecting staff who work drop out or have their treatment withdrawn in drug treatment services, the risks of treatment constitute a group who often have additional to the patient or others, and minimising the risks needs and who might benefit from receiving to clients of having their treatment withdrawn. extended periods of treatment rather than less. The policy framework developed by the Drug treatment services will want to work more NHS Security Management Service, the effectively with this client group in line with strategic lead in this area, is discussed and a best practice. stepped approach to responding to violent and In most instances discharging clients for non-violent incidents is advocated.5 using illicit drugs or alcohol while in drug treatment is not recommended clinical practice. Completing treatment The Drug Misuse and Dependence: UK guidelines on Leaving treatment in an unplanned way is clinical managementgives guidance on responding associated with a worse outcome. Research more effectively to clients who are failing to shows that outcomes improve with time spent in benefit from treatment.3This guide revisits this treatment. Over time, a greater proportion of subject and provides further consensus-based clients who are retained in effective treatment examples of good clinical practice for common should start to achieve their treatment goals and scenarios such as ongoing illicit heroin and crack begin to leave treatment in a planned way. use, co-existent problematic alcohol use, missed Facilitating social re-integration is one of the appointments, failure to collect prescribed aims of treatment and is an important element of medication and dropping out of treatment when the new drug strategy.6There has been a transferred between agencies. growing interest in recovery from dependence In addition to discussing clinical scenarios, on drugs of misuse. Further integration of the this section stresses some important underlying principles of recovery into the drug treatment the continuity of care for clients passing through components of high quality treatment. These system is likely to be the next challenge to the criminal justice system, and inpatient and include comprehensive assessment of need, improve treatment outcomes and increase the residential settings having higher levels of developing a care or treatment plan, delivering proportion of clients who successfully complete clients having their treatment withdrawn than effective interventions, care plan review and treatment. To facilitate more clients to complete other treatment modalities. outcome monitoring. treatment successfully, drug treatment services There is compelling evidence that clients may need to improve their competency in Treatment engagement and retention who drop out of treatment are at significant risk enabling people to achieve their aspirations, Most clients who drop out of treatment do so of returning to illicit drug use, injecting, blood- reach treatment goals, build social and personal between initial assessment and the start of borne virus transmission, committing acquisitive capital and strive for abstinence when they are treatment or in the first few weeks after entry to crime –and dying from opioid overdose. ready. treatment. Continuous effective drug treatment can be Research shows that a range of highly protective against overdose: it can be life interventions can help to engage and retain saving. The challenge for the clinician is to REFERENCES clients in treatment.2These include: the use of develop a treatment plan that maximises 1. National Treatment Agency for Substance Misuse encouraging reminders for appointments; retention in effective treatment but minimises (2009) Towards Successful Treatment Completion – a interventions to boost motivation to engage with the risks to the client and the community. good practice guide. London, NTA. treatment; quicker entry times to treatment; a By sustaining retention of clients in 2. National Treatment Agency (2004) Engaging and more structured induction phase to treatment; optimised and effective treatment there is likely Retaining Clients in Drug Treatment. Research to Dr John Dunn, accompanying clients to appointments; and the to be a greater chance that they will accrue the practice: 5. London, NTA. Consultant Psychiatrist and use of elements of assertive outreach to enhance full benefits of treatment, achieve the goals of 3. DH and devolved administrations (2007) Drug Misuse CANDI Trust engagement. their care plan, complete treatment in a planned and Dependence: UK guidelines on clinical Clinical Team way and be successfully discharged from drug management. London, DH. Leader, NTA. Treatment delivery – responding to failure to treatment services. 4. Fugelstad A et al. (2007) Methadone maintenance benefit from treatment treatment: the balance between life-saving Once clients have been engaged and retained Withdrawal of treatment treatment and fatal poisonings. Addiction 102 (3): for an initial period of treatment, they are still at Although less than 5% of clients have their drug 406-412. risk of dropping out, especially when they or treatment withdrawn by their service provider, it 5. National Health Service Security Management their clinicians feel they are no longer benefiting can be a controversial subject. Treatment is Service (2007) Tackling Violence Against Staff – from treatment. For many clients treatment can sometimes withdrawn when there is violence, explanatory notes. London, NHS SMS. take months or even years before maximum threats of violence or other untoward incidents. 6. H M Government (2008) Drugs: Protecting Families benefits accrue. During this time there may be Treatment may also be withdrawn when there is and Communities SCANbites, Autumn 2009 | 9 CLINICAL CONUNDRUM FORENSIC PSYCHIATRIST’S Clinical RESPONSE Conundrum This patient would benefit from a full and immediate multidisciplinary assessment of his current mental health, degree of substance dependency and control, and a review of his risk profile. The multidisciplinary assessment would be aided firstly by the immediate gathering of all information that was available concerning the man's previous mental health history, dependency history and background. In particular the multidisciplinary team should attempt to receive as much information as possible regarding the patient's previous offending history and details regarding the alleged offence. Information could be gained further from the patient's solicitor, from the SCENARIO MAPPA and from police. The multidisciplinary assessment A 45-year-old man, who has primary alcohol dependence but is also prescribed high dose methadone will give an indication as to maintenance treatment for his previous opiate dependence, does not wish to start reducing his methadone whether this patient continues to nor stop drinking. He has a repeated violent offending history and has recently been bailed for a charge of present with no evidence of a murder. He is currently on level 2 MAPPA and is stopped by the police on a weekly basis for possession of major mental illness. an offensive weapon. Although he has been convicted of possessing an offensive weapon several times in Nevertheless there must be the past, he has repeatedly received bail for these offences. On review of the previous psychiatric notes concerns that an individual who and from his own personal history, he shows a pattern of behaviours since childhood that would appear to has long carried a weapon is now indicate a diagnosis of unsocialised conduct disorder and in his adult years his behaviour appears to being investigated for possible suggest dissocial and psychopathic personality traits; however, this has not been formally assessed. There involvement in a major act of is no indication of the existence of a major psychiatric disorder. violence. The team will need to confirm that this is not associated How should this patient be best managed? with any change in his mental ADDICTION This allows for a safer assessment there is a potential racial element the service user, should be and a reduction in the to the risk profile. Is the briefed of the management plan PSYCHIATRIST’S information requested of the offending always alcohol-related for the assessment. RESPONSE service user. Given the risk or also when sober? Are there any history, we need to consider the child protection issues? The key is to engage the service risk to staff, public and other user and see what they want from IMMEDIATE service users. Can we obtain an Ensure the team involved in the treatment. It would be helpful to MANAGEMENT OASYS form from probation? assessment has discussed the see if there is a significant carer Before the appointment at our The OASYS is a good way of case before the day of who could help improve Specialist Addiction Unit, we looking at the risk history and the assessment; does it need two engagement and retention. A would gather as much people who were previously people? At morning handover all brief history only may be information as possible from the victims and could clarify issues the team, including the appropriate at the first visit, agencies involved, preferably such as whether strangers are at receptionist, who will be key in obtaining enough information with the service user’s consent. risk, women and men, or whether making the first interaction with and corroboration e.g. drug 10| Supporting specialists, promoting consensus

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“The cheap option is no bites SCAN longer ‘cheap and cheerful’ but can be actively harmful”Page 5 The quarterly newsletter of the Specialist Clinical Addiction Network | Autumn 2009 | Volume 6 Issue 3 ISSN 1744-6112 In this issue ! We lead this issue of SCANbites with an article from Peter Rice looking at how Scotland is blazing the trail with alcohol policy, together with a summary of a new Scottish alcohol needs assessment. John Dunn summarises a new NTA publication Towards Successful Treatment Outcomes (page 8) ! The retendering debate continues with responses to the findings of the recent SCAN survey from nurses by Jim Jones, Chair of ANSA (page 4) and André Geel, Chair of the Addiction Faculty of the BPS (page 5). Clearly we are not alone! ! The At your service series continues with Mike Kelleher describing the development of Scotland takes action on alcohol addiction treatment in Brixton Prison (page 12), while Sue Ruben tells us how she survived the transition from addiction Peter Rice psychiatry to general adult psychiatry (page 6). The new clinical conundrum series is launched In April 2009 Kenny MacAskill, the alcohol, across all age groups, is closely with three views on how to manage a Scottish Cabinet Secretary for Justice, related to low cost and ready availability, and complex spoke at the Royal College of that the major problem area is the forensic Psychiatrists Addictions Faculty supermarket sector. problem – meeting in Edinburgh and no one who In March, Christine Grahame MSP, featuring the heard him will be in any doubt that the convenor of the Parliament’s Health and observations of Scottish Government means business in Sport Committee and a convert to action on an addiction doing something about alcohol problems. price, said, “I have great concern for the psychiatrist, a What currently distinguishes the hidden numbers behind the net curtains of forensic Scottish approach is that in addition to ideas Scotland, who are putting alcohol in their psychiatrist and on consensus issues such as public supermarket trolleys on buy-one-get-one- a MAPPA education, product labelling and tackling free promotions when they would not coordinator alcohol-related crime, the Government has normally buy it; because alcohol is within (page 10). What happened in Brixton? invested a considerable amount of money, easy reach, they are taking it in the way that £125m, in prevention and treatment, with an they used to drink a cup of tea at night.” emphasis on brief interventions, as well as The 10-15% increase in alcohol-related ! Caroline Cooper reviews expanding specialist services to cope with acute hospital admissions in the over-50s a new book “Community the considerable unmet need. over the past five years suggest she is right treatment of drug misuse” and that action is needed which affects the by Nick Seivewright (page What has prompted this? behaviour of the whole population. This 7), and Aideen O’Kane reflects on the recent What has really stirred things up, though, challenges the comfortable consensus that SCAN conference for have been the proposals to change the the concerns are only with younger people trainees and new availability of alcohol, in particular, the price. and those with an obvious alcohol problem consultants (page 14). The Government has accepted the analysis and the task is to “tackle” these groups and that the chronic health harm caused by leave “the sensible majority”undisturbed. " www.scan.uk.net SCOTTISH STRATEGY " Minimum pricing minimum pricing. The Scottish Treatment access in Scotland So what is the proposed action on Licensed Trade Association, whose price? The medical profession, members are typically owner- including addiction psychiatrists, operated pubs who pride themselves have had quite a bit to do with this. on high standards of practice, have In 2007, Scottish Health Action on supported the policy since its Alcohol Problems (SHAAP), a group inception. Others such as the British established by the Medical Royal Innkeepers Institute and the Colleges in Scotland, produced a Campaign for Real Ale (CAMRA) report on price which called for a have overcome their initial “we don’t minimum price for alcohol. This want more regulation” response and recommendation was based on: now support the measure. There has been the recent support of Tennents, ! A review of the considerable Scotland’s leading lager brand, and Scotland’s population has better access to evidence base on the Molson Coors, the makers of Carling, alcohol treatment than England’s, in spite relationship between price and to explore minimum pricing as a of a higher prevalence of alcohol harm. means of ending deep discounting. ! Evidence that the other most Producers have become increasingly dThepe efnirdste nnaceti onnoartl ha locof hthoel nbeoerddes ra. ssessment commonly used price control public about their resentment of the for Scotland, published in August 2009, mechanism, excise duties, were power of the supermarkets in found an alcohol dependence prevalence no longer effective in the UK as imposing low wholesale prices and of 4.9% in adults, compared with 3.6% in producers and retailers absorbed using alcohol as a loss leader to get England.1,2The study was commissioned these costs. ! E vidence that the price that customers into their stores, where by the Scottish Association of Alcohol and they make their profit on other goods. Drug Action Teams and funded by the mattered most was that of the Scottish Government. cheapest alcohol, so action on The Alcohol Bill: watch this space Overall, 1 in 12 Scots with alcohol the “floor price” was more important than at the expensive All these political and business dependence gained access to treatment in end of the market. battles might seem remote from the 2006/07 compared with 1 in 18 in England ! A legal opinion that, contrary to interests of the average practitioner in in 2004: a 48% higher level of access in what the alcohol industry had the field, but price is the most Scotland. This is likely to be accounted for been saying for years, a important factor in determining what by the 50% higher spend on alcohol minimum price policy may not alcohol-related harm comes through treatment in Scotland: £296 per breach competition law in the the doors of our clinics and hospitals. dependent drinker in Scotland compared UK or European Union because The Scottish Parliament will vote on to £197 in England. Governments were entitled to an Alcohol Bill, including the As this data was collected before act to protect public health. minimum price proposals in the publication of the new Scottish alcohol strategy and the related new investment autumn. We have a minority in alcohol treatment services, this situation Since that report, further work has Government and nothing is certain, is likely to improve further. Welcoming the emerged from Petra Meier and but the health voice has been report, Dr Michael Farrell, Chair of the colleagues from the University of important in the debate so far and RCPsych Addiction Faculty said, “Scotland Sheffield, available on the those of us involved plan that it will has shown the way within the United Dr Peter Rice, Department of Health website, remain so. Kingdom and in Europe with innovative, Consultant which supports the SHAAP evidence-based approaches to prevention Addiction conclusions. The Chief Medical FURTHER READING and treatment of alcohol problems. Other Psychiatrist, Officer in England, Prof Liam Governments would do well to follow a Tayside Alcohol Donaldson, followed the Scottish Scottish Government (2009) Changing similar approach.” Problems lead when he called for minimum Scotland’s Relationship with Alcohol: A Service, Primary pricing in his Annual Report in March Framework for Action.Scottish Care Division 2009. Government, Edinburgh. REFERENCES NHS Tayside, 1 Drummond, C., Deluca, P., Oyefeso, A., Rome, Sunnyside The industry response Drummond, C., Deluca, P., Oyefeso, A., A., Scrafton, S., Rice, P. (2009) Scottish Royal Hospital, There has been a quick response Rome, A., Scrafton, S., Rice, P. (2009) Scottish Alcohol Needs Assessment.Institute of Hillside, Psychiatry, King's College London: London Montrose, from some parts of the alcohol Alcohol Needs Assessment.Institute of (www.saadatonline.co.uk/word_docs/Scottish Angus industry to this work. The Scotch Psychiatry, King's College London: London %20Alcohol%20Needs%20Assessment.pdf) Whisky Association has led the 2 Drummond, C., Oyefeso, N., Phillips, T., charge against minimum pricing in Scottish Health Action on Alcohol Problems Cheeta, S., Deluca, P. et al (2005) Alcohol Scotland and SAB Miller (formerly (2007)Alcohol: Price, Policy and Public Needs Assessment Research Project (ANARP). South African Brewers) Health.SHAAP, Edinburgh. shaap.org.uk The 2004 national alcohol needs assessment commissioned a report to counter the for England.Department of Health: London (www.dh.gov.uk/en/Publicationsandstatistics/ University of Sheffield findings. Information and Statistics Division (2009) Publications/PublicationsPolicyAndGuidance/ Other parts of the alcohol Alcohol Statistics Scotland 2009.Scottish DH_4122341) industry have been supportive of Government, Edinburgh. alcoholinformation.isdscotland.org 2| Supporting specialists, promoting consensus Comment We are not alone! Colin Drummond In the last issue of SCANbites we can it be, for example, that the local needs highlighted the growing concerns of are deemed to be so divergent across nine addiction psychiatrists about the adverse adjacent London boroughs that the clinical impact of increasing retendering of NHS psychology provision varies by a factor of 7, addiction services across England. Since from 0.2WTE in one borough to 1.4WTE then Starship SCAN has boldly gone to in another? other parts of the addiction Universe to explore the views of other specialists in the In yet another galaxy the BMA News field. And clearly we are not alone. highlights similar concerns about the wider NHS in which “finances are being Jim Jones, Chair of the Association of prioritised over care, there is falling Nurses in Substance Abuse, highlights in investment in research and training, and an this issue the concerns of specialist nurses emphasis on profits.”1In their view the in the field (page 4). The same concerns “marketisation” of the NHS, with contracts about disruption to patient care, damage to moving to the independent sector, will staff morale, and replacement of trained have lasting damage on quality of care and specialist staff by people with less workforce training for many years to come. experience and qualifications are shared by Medical training, both for undergraduates nursing colleagues. and postgraduates, appears to have little or no place within new independent sector For those nurses who remain in services contracts or ethos. after re-tendering their continuing professional development is often not So, far from being a problem uniquely financially supported and some nurses re- affecting addiction psychiatry, politically employed under TUPE within 3rd sector driven changes in commissioning practice organisations report being financially worse are raising remarkably similar concerns off. However, their main concern is about a across professions in addictions and the financially driven agenda prioritising wider NHS. As these changes are quantity over quality. Similar concerns are undermining NTA and Department of also highlighted in a consultant nurse’s Health policy, as highlighted by Dr Geel, it letter to SCANbites in this issue (page16). is time for these organisations to formally examine the impact of commissioning Meanwhile in the clinical psychology solar activity on the quality of care and system Dr André Geel, Chair of the British professional training in England. Psychological Society Faculty of Addictions, raises concerns about the The contributions from different future quality of psychological professions in this and the last issue of interventions (page 5). In an environment SCANbites highlight that we share the where clinical psychology leadership is not NTA’s and Department of Health’s vision being appropriately prioritised, he is of the need to improve the quality of concerned not just that psychological addiction treatment. However, this is therapies may be ineffective and at odds unlikely to be achieved in an environment with NTA and NICE guidance, they may where these aspirations are afforded such a potentially be harmful in the wrong hands. low priority at a local level. It may be Dr Geel also highlights what has become a addiction treatment, Jim, but not as we postcode lottery due to differences in know it... nor, indeed as good as it could commissioning priorities for specialist be. professional staffing. Clearly this issue goes beyond the narrower concerns about re- Professor Colin Drummond is SCAN Lead tendering, raising questions about the wisdom of a policy which allows, or even REFERENCE encourages, such wide diversity in 1. Anonymous (2009) Medics rally to anti- commissioning of service provision. How market campaign. BMA News, August 29. SCANbites, Autumn 2009 | 3 RE-TENDERING Specialist nursing observations on the SCAN retendering survey Jim Jones ANSA members report similar informed, political elements. This can nurses with a specialist addiction experiences to those outlined in the include pressure groups with particular background. Of course their position as agendas, and evidence-based treatment commissioners means their skills are lost SCAN survey of addiction principles can suffer. It seems there is to clinical practice, and their skills as psychiatrists. The process of little understanding of what nurses can commissioners are variable due to lack of recommissioning should be one of do; their knowledge, skills and specific training for that role. experience acquired during a 3-year Nurses who have worked in the improving effectiveness, but has all undergraduate professional training may NHS can be TUPE’d across to the new Jim Jones is Chair of the the hallmarks of being cost-driven, make them more difficult to manage; but provider. However, this can lead to Association of with little understanding shown in drug workers with lesser ability or problems with NHS pensions if it is to a Nurses in many cases by commissioners of the professional qualifications are in many 3rd Sector provider, and risks becoming a Substance cases being deployed in services to take ‘gap in service’ if a move back to the Abuse (ANSA). nature of the work being done, or of on the same role at the same salary. For NHS is part of further career the nature of nurses’ roles within it. medical staff it means they will not be in development. The re-commissioning receipt of the support nurses can give to process can result in a cost saving of 20% The process is certainly disruptive, with their role, whilst drug workers often because the new pension arrangements services that cannot see what that support may need are much cheaper for the employer. have lost to be, nor have the ability to provide it. This, of course, may be part of a much contracts RMN trained nurses in particular report bigger financial agenda. running down poor recognition of what they can offer in The concept of “World Class in the months the care of complex service users. Commissioning” has much to offer in Florence before the new Service-users are, of course, worse-off as terms of revitalising service provision Nightingale ones take over, a result. and avoiding complacency. (Although and with little Prison-based nurses report that the the “World” seems limited to the UK in effective handover complex nature of that work is not the manner in which it operates.) occurring. Staff leave recognised by the commissioning However, the devil is in the detail, when faced with an process and new contractual and the detail often means a dumbing uncertain future, the good arrangements are aspirational to the down, cost-driven exercise where ones find work in neighbouring areas point of being pie-in-the sky in terms of professional standards are paid only lip- that have ‘new’ services starting up, the likelihood that goals will be met. service. It must not be forgotten by those leaving behind understaffed services The lack of recognised standards of us who work in the field clinically, that with low morale to trickle on with and qualifications for the role of our client group are not always held in unfilled (and unfillable) posts. Service- commissioner means that nurses have the highest esteem and that in the eyes users do not know how they will found themselves having to defend of outsiders we can be contaminated by continue to be treated after the change accepted professional-practice standards that association. High quality, more until the last minute, and many well- as part of the contracting process. Job costly services for those who some may established therapeutic alliances have descriptions are pared to the bone, regard as ‘criminal deviants’ will not been broken by the particularly the requirement for clinical score heavily with the electorate. On the recommissioning process. supervision and continuing professional other hand the commissioning process Nurses report that many development, which in many instances is needs to recognise that professional commissioners have no left completely financially unsupported nurses who choose to work with this background in drug treatment, within new service contracts. This client group are not attracted by the sometimes no background in emphasises the short-term nature of same things that exist in other areas of health or social care, and are many contracts, with little chance to health care, and that it would be all too dependent on others for grow mature teams, or develop well easy to drive them away into more guidance. This leaves them trained and supported staff. popular, better recognised fields of open to influence from ill- Commissioners do include some practice. 4| Supporting specialists, promoting consensus READY TO BE FIRED? The clinical psychology perspective André Geel The recent SCAN survey raises some better as quickly as possible by consultant psychologists to those who very interesting issues – both threats receiving appropriate and effective are less skilled and experienced. and opportunities, and pros and cons. treatment. However, in my It seems pertinent to all professions, experience this has not always been Indeed, it would be clinically effective but I will respond from the the case. to have a consultant psychologist in perspective of clinical psychology and post in a borough, who would then my own clinical experience in some In my current post, I am in the supervise psychologists, key workers, London boroughs. fortunate position to be able to nurses, and CBT therapists in Dr André Geel, observe both directly and indirectly, psychosocial interventions, as opposed Cluster Lead There are very few Clinical the functioning of both general and to counsellors using eclectic (a Consultant Psychologists working in the psychology-specific addiction services mixture of humanistic, Clinical addictions field. They number in nine London boroughs. I also psychodynamic and other) Psychologist, somewhere between 100 and 200 directly supervise the psychologists in interventions which are not evidence- CNWL Foundation spread across the United Kingdom. four of those boroughs. It is clear that based, and which are indeed clinically Trust, London, and As a profession they represent the the way that psychology services in ineffective, counter-therapeutic and Chair of the “Psychology of Addiction” – the these different boroughs are contra-indicated. (See page 14 of Faculty of behavioural, cognitive, interpersonal commissioned varies hugely. Across Psychosocial Interventions for Drug Addictions, British and non-medical, non-chemical/non- the nine boroughs, consultant Misuse, 2009.) Psychological pharmacological view of the addictive psychologist posts range from 0.2 Society process. Within their teams, services WTE (whole time equivalent) to 1.4 The cheap option is no longer “cheap and organisations they are ideally WTE and other psychology posts from and cheerful” but can be actively positioned to be standard bearers and 0.0 WTE to 4.0 WTE. harmful. Based on the above champions for the psychosocial evidence it is possible that some interventions so comprehensively The value that commissioners place services that are commissioned purely highlighted by NICE and others in on quality appears to vary greatly and on a low budget may actually be the last few years. there appears, in some cases, to be making patients worse, when if a little little awareness of the need for high more money was spent more carefully, With the publication of the NTA’s quality such as, for example, the service could be designed to make “Psychosocial Interventions for Drug consultant psychologist posts as a patients better. Misuse” in 2009 we now have three consistent need. Much of the more consecutive years of guidelines and recent commissioning discussions The Hippocratic Oath of “do no literature attesting to the need for focus on cost and are not quality- harm” applies equally to the “professionalism”: the Darzi report, driven. There appears to be very little psychosocial interventions, and we “High Quality Care for All” in 2008 awareness or acknowledgement of should ensure that we design services and for “clinicians to inform strategy, NICE, NTA or Department of Health in a way that includes a quality control and drive quality, service design and guidelines. In some local boroughs element, which will in turn ensure resource utilization” from the services appear to have been clinical effectiveness. The least one Department of Health’s “World Class commissioned on their cost alone and could do would be to have a Commissioning” in 2007. From this, not on whether they were NICE or consultant psychologist as lead the message seems clear and the NTA-compliant. It is my experience clinician for psychosocial interventions evidence overwhelming that that a number of non-NHS providers, in each service. This would ensure commissioners must commission who are not required to have that the workforce is appropriately services that ensure that patients get consultant-level or chartered trained and supervised, and that psychologists as part of their staff patients are seeing the right therapist complement, have been using the right intervention. commissioned to provide psychosocial interventions without being We have now reached a point in the NICE/NTA compliant, or without development of psychological commissioners placing NICE/NTA- compliance as a requirement for a treatment where we know which successful bid. treatment works for which disorder and with which patient. We need to I do believe that it is possible to commission an affordable service and ensure that our workforce reflects for it still to be NICE/NTA- this knowledge and does not compliant, but it takes some time to continue to repeat old mistakes. design such a service as the details involve looking at skill mix, workforce Commissioners need to use this redesign, key worker and drug worker knowledge constructively and competencies, as well as requirements intelligently as part of their for supervision and training, and the required ratios of experienced, commissioning process. Ivan Pavlov SCANbites, Autumn 2009 | 5 LIFE AND POETRY appreciation of the subtle and complex interplay between mental illness and substance misuse. All posts have service development opportunities, and negotiation skills are well developed when coming from addiction, to say nothing of our finely tuned Confession bullshit detectors! There are, of course, differences. I’m addicted New teams with strange names To now exist. There were a few Addiction medications I had never prescribed, (in a healthy way of course) but surprisingly few in fact and easy Life after addiction psychiatry to learn. I hadn't been to a Mental I crave Health Review Tribunal for years The and I found the first few tough. My (or how to return to the adult Chaos ever sharp tongue got me through. Stories world and survive it) I am glad I kept up Section 12 Variety Approval and stayed on the on-call Stimulation rota. It was surprisingly easy to get Frustration stuck into a new job with a Even perhaps the NTA Sue Ruben different patient group and new (Well let’s not get carried My career plan, not that I'd have helpless and made a decision to challenges. My sense of humour away) called it that, was to stay in return to adult psychiatry rather than returned. Liverpool Drug Services until await my fate. A job was available I did grieve. I couldn't drive past I retirement or death. With the with colleagues I knew and liked in my old office without crying, Dream relentless move to the cheap and Wales, and it was commutable from necessitating a change of route to Of cheerful "no frills services" (or Liverpool. my new job – red eyes are so A relapse Back "Easydrug" as I called them), The move back to the adult world unattractive in a woman of my age. To drugs and alcohol addiction psychiatrists were to me, was daunting. I managed it while To this day I have a ridiculous gripe an endangered species surrounded keeping a foot firmly in the that irks me. I didn't get my Friends sigh by predators replacing full-time addiction world. Here are some picture in "Trust Matters" when I You look Consultants with sessional GPs. thoughts which may help others left – the only Consultant ever not So well The day in early 2005 when I who have to make a change and for to be so honoured. Now that I work Rested uncovered the plan to dispense with trainees who aspire to addiction but in Adult Psychiatry I do not forget Happy my post was a strange one. I where no suitable post is available. my first love, Addiction. And I am realised too late that, having The skills required to be a I have negotiated a personal relinquished my role as Clinical Consultant Psychiatrist are largely development plan allowing time for But it’s always there Director, I had lost any semblance of transferable across sub-specialities. addiction courses and conferences. An insistent influence over any aspect of local We have a lengthy training and I offer second opinion work for the Nagging services including my own. I was a background in mental disorders local addiction services. I volunteer Little voice dinosaur facing extinction. within a broad based socio-bio- for groups that are relevant to my In My popularity with colleagues and special expertise. I teach on The back of TRANSFERABLE SKILLS service users meant nothing as I did addiction topics within mental My head not have the support of the Trust's psychological model. Our strength health services locally, and on the executive team, local should be in bringing leadership Liverpool MRCPsych Course. I Be warned commissioners, or the NTA. The qualities and a real understanding am involved in an alcohol research It’s with you For life letter I had written expressing my and commitment to multi- group in North Wales with a concerns on matters of clinical disciplinary working. funded project underway. I hope governance had won me no friends A background in addiction gives us My final advice is to make the best in the organisation, nor had my fairly much experience in working across of whatever job you do and it will extensive knowledge of the traditional boundaries. We are used be interesting. I would return to literature and evidence base, which to forming therapeutic relationships my first love if an opportunity arose seemed to irritate rather than with hard to engage patients – my but, if not, I will continue to enjoy educate. personal favourites. Adult the adult world, my new colleagues "I feel like a character in a Kafka psychiatry teams often find and the privileges that a career in Dr Sue Ruben, novel," I said to the manager, who substance misuse issues hard to psychiatry has brought me. consultant in was unmoved and merely informed tackle, despite the high prevalence I finish with a short confessional general adult me that he had never heard of Kafka within their populations. They poem which I recently wrote on the psychiatry, North Wales NHSA Trust so couldn't comment. I felt ill and welcome expertise and an train to Bath. 6| Supporting specialists, promoting consensus BOOK REVIEW detail and illustrated with case histories, work is barely mentioned and service with shorter sections touching on commissioning is not discussed at all. methamphetamine, khat, cyclizine, The book gives the impression that most hallucinogens, steroids and solvents. drug treatment services are placed within Cannabis, alcohol and nicotine are discussed the NHS – hopefully by the publication of only in relation to their implications for drug the 3rd edition, this will still be the case. A services, without addressing the chapter is devoted to drug treatment in management of patients with problematic primary care, and another to dual diagnosis use of these substances alone. and the overlap between drug use and Case histories are scattered throughout mental disorder (including personality the book, and bring the text to life. disorders). Although I’m sure there was a temptation to It could have been written with me in mind use positive examples of how treatment brought about marked changes in the The final chapter before the appendix patient’s circumstances, (“patients” or (protocols for various detoxification regimes substance “misusers” throughout, rather for heroin) looks at liaison work and special than clients or service users), many examples patient groups: work within general show less-than-good outcomes, which hospitals and prisons, with pregnant reflect the realities of providing treatment women, adolescents, and older patients for our particularly challenging group of who are at greater risk of physical health patients. problems. Physical issues such as pain and The book does not shy away from blood-borne viruses are also reviewed with controversies of drug treatment in the respect to their impact on addiction services. community: the fact that in prescribing we The book could have been written with replace one addictive substance with me in mind – it is a more readable guide to Community treatment of another, or that patients abstinent from one practice than the orange guidelines, and I substance may start using an alternative; would certainly recommend it as a valuable drug misuse: More than difficulties in defining success of treatment companion for psychiatrists starting out in (psychosocial stability versus abstinence, the this field, for drug workers to understand methadone Nick Seivewright, current recovery agenda conflicting with the more about the medications we use and assisted by Mark Parry need to retain patients in treatment); the why, and to GPs working in addiction (who role of treating individuals to benefit wider may not have had the opportunity to Review by Caroline Cooper society; and enforced treatment as a experience as full a range of psychological potential alternative to custodial sentences and supportive interventions as those with a in the criminal justice setting. psychiatry background). The difficulties in providing treatment to Unfortunately, it is limited in providing Many will be familiar with Nick people living in socially deprived areas with information on pharmacological and Seivewright’s original book on occasionally questionable motivation to biological mechanisms (although the 25 the community treatment of change are also referred to. pages of references at the end provide a drug misuse, and its beguiling Following the introduction to sound starting point for those wanting to sub-title “More than methadone”, which he community treatment of addiction and a read up on this material), and it may lack originally chose to encourage services to review of methadone, associated treatment the detail desired by more experienced incorporate psychological approaches to aspects are examined – counselling, clinicians. However, they too may benefit treating opiate misuse and to offer treatment contracts and drug testing, and from a book which provides thought- treatment for drugs such as cocaine for safe prescribing. Different pharmacological provoking opportunities to re-examine which there is no substitute prescription. approaches to opiate detoxification are theoretical and practical aspects of their Originally published in 2000, when the covered, followed by strategies for work. use of buprenorphine was in its infancy and preventing subsequent relapse. Strengths LAAM was still prescribeable, this has been and weaknesses of other opiate substitute !Seivewright, N. (2009) Community updated with a second edition providing an drugs (in particular buprenorphine) are Treatment of Drug Misuse: More than updated resource whilst remaining true to discussed, as are prescription amphetamines methadone, 2nd Ed. Cambridge University the original aim: to provide practical advice and benzodiazepines, although the lack of Press, Cambridge. based on scientific evidence. mention of modafinil as a potential Dr Seivewright is assisted by Dr Mark substitute treatment for stimulant use may Parry in providing a more comprehensive, age this edition of the book. updated literature review alongside practical The second section of the book information. This focuses on opiates, but addresses service provision: the also includes the effects, complications and development of community drug services Dr Caroline Cooper, SCAN treatment of other substances of abuse. Of and the organisation of teams, but Trainee and specialist registrar, these, cocaine, amphetamine, ecstasy and unfortunately the increasing role of non- Nottingham Healthcare Trust benzodiazepine misuse are covered in most statutory drug services in providing Tier 2 SCANbites Autumn 2009 | 7 NTA Towards successful outcomes Preventing unplanned discharges from drug treatment services John Dunn The NTA has developed guidance for services in England. Seventy eight percent who dropped out of treatment may no longer service providers and commissioners on entering drug treatment were retained in need treatment. good practice in preventing unplanned treatment for at least 12 weeks and a further 4% In 2007/08 69,642 individuals were discharges from drug treatment services: had a planned discharge before 12 weeks. discharged from treatment of which 51% Towards successful treatment completion – a Whilst successfully retaining clients in successfully completed treatment and were said good practice guide.1This article summarises treatment for 12 weeks or more is an important to have had a planned discharge. However, 48% the main areas that the guidance covers. proxy for the delivery of effective strategies to had an unplanned discharge, with treatment engage and retain clients in treatment, it does drop out being the commonest reason (28%). Background not always translate into clients subsequently There has been a downward trend in The document examines the reasons why successfully completing their treatment and unplanned discharges from 71% of individuals clients may not complete drug treatment and leaving treatment services in a planned way. leaving drug treatment in 2004/05, to 66% in examines factors involved in successful planned If a client chooses to leave treatment in an 2005/06, 58% in 2006/07 and 48% in 2007/08, discharges; reviews the research on measures unplanned way, often before their goals have which adds credence to the potential for designed to improve engagement and retention been fully achieved, or if treatment is optimising further the number of planned in treatment; and gives examples of good clinical withdrawn, the client can be said to have had an discharges that can be achieved. practice aimed at improving treatment unplanned discharge. Whilst not all do badly effectiveness and successful treatment after such a discharge, it is generally considered The profile of unplanned discharges outcomes. By engaging and retaining clients in good practice to maximise planned discharges. There is considerable variation between effective treatment, it is anticipated that more Unplanned discharges occur for a range of partnerships in the rate of unplanned discharges. will achieve their treatment goals and leave drug reasons, the commonest being dropping out of Data from the National Drug Treatment treatment in a planned way. treatment, followed by going to prison, Monitoring Service (NDTMS) and the Drug The development of the guide was treatment being withdrawn, the client declining Interventions Record (DIR) are presented in the supported by an expert advisory group the treatment offered or moving away and losing good practice guide. The analysis shows that established for this purpose, and was finalised by contact with the treatment service. ‘service factors’ have a much bigger impact on its agreement. The group included An unplanned discharge does not treatment outcome than client characteristics. representatives from addiction psychiatry, necessarily mean that treatment was a failure. However, drug(s) of misuse also has an impact, primary care, research, addiction nursing, For example, clients who are discharged because in particular combined opiate and crack use pharmacists, NHS treatment providers, the non- they have gone to prison should have their increases the risk of having an unplanned statutory sector and client advocacy groups. treatment continued under the Integrated Drug discharge. Other important themes identified in For 2007/08, 202,666 individuals were Treatment Systems (IDTS) that have been the analysis include: some stimulant users being recorded as being in contact with drug treatment introduced in the prison estate. Some clients unable to access treatment services, problems in 8| Supporting specialists, promoting consensus setbacks – clients may relapse or increase their no sign of progress or when there is evidence of levels of illicit drug use or fail to reach the goals deterioration in treatment. Withdrawing set with keyworkers. Helping clients develop treatment that involves substitute opioid strategies to deal with these challenges is an prescribing puts clients at significant risk of essential aspect of clinical care. relapse back into illicit heroin use and is This section of the good practice guide associated with increased risk of drug-related discusses the evidence that inflexible treatment overdose death – 20 times higher than that of packages, punitive responses to continued illicit clients who stay in treatment involving drug use and a poor therapeutic alliance militate prescribed opioids.4Therefore, a balance needs against clients staying in treatment. Clients who to be struck between protecting staff who work drop out or have their treatment withdrawn in drug treatment services, the risks of treatment constitute a group who often have additional to the patient or others, and minimising the risks needs and who might benefit from receiving to clients of having their treatment withdrawn. extended periods of treatment rather than less. The policy framework developed by the Drug treatment services will want to work more NHS Security Management Service, the effectively with this client group in line with strategic lead in this area, is discussed and a best practice. stepped approach to responding to violent and In most instances discharging clients for non-violent incidents is advocated.5 using illicit drugs or alcohol while in drug treatment is not recommended clinical practice. Completing treatment The Drug Misuse and Dependence: UK guidelines on Leaving treatment in an unplanned way is clinical managementgives guidance on responding associated with a worse outcome. Research more effectively to clients who are failing to shows that outcomes improve with time spent in benefit from treatment.3This guide revisits this treatment. Over time, a greater proportion of subject and provides further consensus-based clients who are retained in effective treatment examples of good clinical practice for common should start to achieve their treatment goals and scenarios such as ongoing illicit heroin and crack begin to leave treatment in a planned way. use, co-existent problematic alcohol use, missed Facilitating social re-integration is one of the appointments, failure to collect prescribed aims of treatment and is an important element of medication and dropping out of treatment when the new drug strategy.6There has been a transferred between agencies. growing interest in recovery from dependence In addition to discussing clinical scenarios, on drugs of misuse. Further integration of the this section stresses some important underlying principles of recovery into the drug treatment the continuity of care for clients passing through components of high quality treatment. These system is likely to be the next challenge to the criminal justice system, and inpatient and include comprehensive assessment of need, improve treatment outcomes and increase the residential settings having higher levels of developing a care or treatment plan, delivering proportion of clients who successfully complete clients having their treatment withdrawn than effective interventions, care plan review and treatment. To facilitate more clients to complete other treatment modalities. outcome monitoring. treatment successfully, drug treatment services There is compelling evidence that clients may need to improve their competency in Treatment engagement and retention who drop out of treatment are at significant risk enabling people to achieve their aspirations, Most clients who drop out of treatment do so of returning to illicit drug use, injecting, blood- reach treatment goals, build social and personal between initial assessment and the start of borne virus transmission, committing acquisitive capital and strive for abstinence when they are treatment or in the first few weeks after entry to crime –and dying from opioid overdose. ready. treatment. Continuous effective drug treatment can be Research shows that a range of highly protective against overdose: it can be life interventions can help to engage and retain saving. The challenge for the clinician is to REFERENCES clients in treatment.2These include: the use of develop a treatment plan that maximises 1. National Treatment Agency for Substance Misuse encouraging reminders for appointments; retention in effective treatment but minimises (2009) Towards Successful Treatment Completion – a interventions to boost motivation to engage with the risks to the client and the community. good practice guide. London, NTA. treatment; quicker entry times to treatment; a By sustaining retention of clients in 2. National Treatment Agency (2004) Engaging and more structured induction phase to treatment; optimised and effective treatment there is likely Retaining Clients in Drug Treatment. Research to Dr John Dunn, accompanying clients to appointments; and the to be a greater chance that they will accrue the practice: 5. London, NTA. Consultant Psychiatrist and use of elements of assertive outreach to enhance full benefits of treatment, achieve the goals of 3. DH and devolved administrations (2007) Drug Misuse CANDI Trust engagement. their care plan, complete treatment in a planned and Dependence: UK guidelines on clinical Clinical Team way and be successfully discharged from drug management. London, DH. Leader, NTA. Treatment delivery – responding to failure to treatment services. 4. Fugelstad A et al. (2007) Methadone maintenance benefit from treatment treatment: the balance between life-saving Once clients have been engaged and retained Withdrawal of treatment treatment and fatal poisonings. Addiction 102 (3): for an initial period of treatment, they are still at Although less than 5% of clients have their drug 406-412. risk of dropping out, especially when they or treatment withdrawn by their service provider, it 5. National Health Service Security Management their clinicians feel they are no longer benefiting can be a controversial subject. Treatment is Service (2007) Tackling Violence Against Staff – from treatment. For many clients treatment can sometimes withdrawn when there is violence, explanatory notes. London, NHS SMS. take months or even years before maximum threats of violence or other untoward incidents. 6. H M Government (2008) Drugs: Protecting Families benefits accrue. During this time there may be Treatment may also be withdrawn when there is and Communities SCANbites, Autumn 2009 | 9 CLINICAL CONUNDRUM FORENSIC PSYCHIATRIST’S Clinical RESPONSE Conundrum This patient would benefit from a full and immediate multidisciplinary assessment of his current mental health, degree of substance dependency and control, and a review of his risk profile. The multidisciplinary assessment would be aided firstly by the immediate gathering of all information that was available concerning the man's previous mental health history, dependency history and background. In particular the multidisciplinary team should attempt to receive as much information as possible regarding the patient's previous offending history and details regarding the alleged offence. Information could be gained further from the patient's solicitor, from the SCENARIO MAPPA and from police. The multidisciplinary assessment A 45-year-old man, who has primary alcohol dependence but is also prescribed high dose methadone will give an indication as to maintenance treatment for his previous opiate dependence, does not wish to start reducing his methadone whether this patient continues to nor stop drinking. He has a repeated violent offending history and has recently been bailed for a charge of present with no evidence of a murder. He is currently on level 2 MAPPA and is stopped by the police on a weekly basis for possession of major mental illness. an offensive weapon. Although he has been convicted of possessing an offensive weapon several times in Nevertheless there must be the past, he has repeatedly received bail for these offences. On review of the previous psychiatric notes concerns that an individual who and from his own personal history, he shows a pattern of behaviours since childhood that would appear to has long carried a weapon is now indicate a diagnosis of unsocialised conduct disorder and in his adult years his behaviour appears to being investigated for possible suggest dissocial and psychopathic personality traits; however, this has not been formally assessed. There involvement in a major act of is no indication of the existence of a major psychiatric disorder. violence. The team will need to confirm that this is not associated How should this patient be best managed? with any change in his mental ADDICTION This allows for a safer assessment there is a potential racial element the service user, should be and a reduction in the to the risk profile. Is the briefed of the management plan PSYCHIATRIST’S information requested of the offending always alcohol-related for the assessment. RESPONSE service user. Given the risk or also when sober? Are there any history, we need to consider the child protection issues? The key is to engage the service risk to staff, public and other user and see what they want from IMMEDIATE service users. Can we obtain an Ensure the team involved in the treatment. It would be helpful to MANAGEMENT OASYS form from probation? assessment has discussed the see if there is a significant carer Before the appointment at our The OASYS is a good way of case before the day of who could help improve Specialist Addiction Unit, we looking at the risk history and the assessment; does it need two engagement and retention. A would gather as much people who were previously people? At morning handover all brief history only may be information as possible from the victims and could clarify issues the team, including the appropriate at the first visit, agencies involved, preferably such as whether strangers are at receptionist, who will be key in obtaining enough information with the service user’s consent. risk, women and men, or whether making the first interaction with and corroboration e.g. drug 10| Supporting specialists, promoting consensus

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