OPR/03 LINCOLNSHIRE PARTNERSHIP NHS TRUST PROCEDURE FOR MANAGEMENT OF DRUG AND ALCOHOL MISUSE DOCUMENT CONTROL Version: 2 (version 1 issued December 2005) Type: Operational p (Tick Appropriate Corporate Services box) Risk Management/Health & Safety Personnel Infection Control Mental Health Act Author: Divisional Manager, East Ratifying Body: PPG Approving Body: Core Management Group Approval Date: 28 th June 2006 Issue Date: September 2006 Review Date: June 2007 Distribution: All Policy Manual Holders p MHA Manual Holders Operational Manual Holders Infection Control Manual Holders Page 1 of 11
PROCEDURE FOR MANAGEMENT OF DRUG AND ALCOHOL MISUSE 1. Policy Context Dual Diagnosis Good Practice Guide (DOH 2002) Misuse of Drugs Act (1971) Personality Disorder no longer a diagnosis of exclusion (NIMHe 2003) Clinical guidelines for the management of drug dependence Models of Care (DOH 2002) National Service Framework for Mental Health (DOH 1999) Police and Criminal Evidence Act 2. Summary 2.1 The Trust recognises that it has a duty of care to all Service Users and, as such, should ensure appropriate guidance to staff to deliver this care. Substance Misuse is common rather than exceptional amongst people with severe Mental Health problems and the relationship between the two is complex. Substance Misuse and Dual Diagnosed Service Users are entitled to receive high quality Service User focussed and integrated care. This should be delivered within Mental Health Services. (Dual Diagnosis Guidelines DOH 2002). 2.2 The Trust recognises that it is an offence if being the occupier or concerned in the management of any premises, he/she knowingly permits or suffers any of the following activities on their premises: Producing or attempting to produce a controlled drug Supplying or attempting to supply a controlled drug to another or offering to supply a controlled drug to another Preparing opium for smoking Smoking cannabis, cannabis resin or prepared opium Supplying or attempting to supply Magic Mushrooms (Section 8, Misuse of Drug Act 1971) 3. Definition. The term Dual Diagnosis is used in this context to describe the combination of severe mental illness (mainly psychotic disorders) and a concurrent Substance Misuse problem. However, this definition does not define the complexities of this condition. The term co-morbidity may also sometimes be referred to in documents. 4. Publicity. All clinical staff should have training in Substance Misuse awareness as part of their induction. The Management of Substance Misuse/Dual Diagnosis Page 2 of 11
5. Notes to Consider. Implicit to this Policy and Procedure is that staff will use information gained from their knowledge of the Service User through the therapeutic relationship and the general circumstances of the situation to facilitate therapeutic risk assessment and management. Staff should balance this relationship with the duty of care to the wider public and if in doubt, seek legal advice from LPT as to how to proceed. 6. Hospital In-Patient Settings. On admission, all Service Users will be assessed and information obtained about their Mental Health and whether there is any substance misuse. Where relevant, the case should be referred to specialist services to assist in determining an appropriate package of care as soon as possible. 7. Immediate Action the safety of Service Users and staff is paramount 7.1 In cases where it is believed that an in-patient has been using drugs/alcohol, this will have been identified by one or more of the following: Staff observing the act/discovering evidence of usage A Service User discloses the information through the process of assessment The person may be observed to be intoxicated Information may be received from a third party (care must be taken to ensure that this information is reliable) Action: Document and discuss with the team to observe for signs and symptoms of intoxification through drug/alcohol use Monitor for changes in behaviour Look for evidence of drug/alcohol usage etc (paraphernalia, signs of overdose intoxification) Use of alcometers/drug testing kits may be used as a part of the care process to inform decision-making, but should not be used in isolation If time permits, wider discussion with the Multi-Disciplinary Team (MDT) will take place 7.2 The person in charge will decide on what immediate action needs to be taken after carrying out a risk assessment: If the Service User is clearly intoxicated, they will be taken to a quiet area and observed Contact the duty doctor if appropriate Monitor vital signs and increase levels of observations Remain aware of any interactions with prescribed medication and omit if necessary/discussion with medical staff should take place as soon as possible) Ensure safe disposal of sharps (needles) Page 3 of 11
7.3 In situations where substances are found on an in-patient or on Trust premises: If illicit substances are present they will be removed for safe keeping as per the local procedure (see Appendix 1) If the Service User declines to hand the substance to staff, a search may be carried out - care must be taken with this and legal advice should be sought if the Service User refuses to be searched. To follow the LPT Search Policy. Alcohol will be removed to a safe place until a decision can be made about appropriate disposal. The alcohol may be disposed of by pouring down the sink with the permission of the owner (if the owner of the alcohol is intoxicated, it would be necessary to wait until they were sober before this happens so that that can give informed consent) If substances are suspected of being hidden on the premises, then a search may be carried out. All decisions should be taken only after consultation with the Ward Manager/Nurse in charge, who may in turn take legal advice and will consult LPT Search Policy. 7.4 Every incident should be assessed on individual merit and decisions re the future management will be at the discretion of the MDT. The option for contracts and specific care plans needs to be considered. 7.5 The option to involve the Police and/or discharge the person can be considered at the review of the Care Plan, eg if the person has been admitted for detoxification and it was part of the agreed plan of care. If the need to discharge the patient or involve the Police is urgent, this should occur prior to the review and in consultation with the Ward Manager where possible. If discharge is the agreed action, consideration will be given to appropriate following up, bearing in mind a risk assessment. Note: Staff should be aware that there is a legal obligation to inform the Police of illicit drug use 7.6 If the Service User is already involved with Substance Misuse services the team should be informed of the situation. If the Service User is not involved with Substance Misuse services and wishes to be referred, every attempt should be made to prioritise their referral to the appropriate service. 7.7 Risk of overdose by restarting illicit drug use should be a serious consideration and advice should be given to the Service User on discharge via harm reduction information leaflets/packages etc. Staff need to be aware that the highest overdose risk period of substance users is following a period of admission, be that in a ward, prison or other long term establishment. 8. Supplying of Illicit Substances - the safety of Service Users and staff is paramount 8.1 If there is knowledge that illicit substances are being passed to a third party by another Service User (staff will have observed the act): Page 4 of 11
Staff should be aware that they have a duty of care to the Service User but also a legal obligation to prevent this happening and to inform other relevant parties as per the Drug Act (1971) If the practice continues, the review of care may result in discharge unless the Mental Health state indicates that they are at immediate risk to themselves/others. It may be that at this point the Service User supplying the substance will require a more secure clinical environment. 8.2 Staff are to, after carrying out a risk assessment, ensure that they will not be at risk of harm, and: Inform the Service User that this is an illegal activity Inform the Service User that this incident will be discussed with Responsible Medical Officer (RMO) and MDT with possible Police action Inform Service User that continued dealing will definitely result in Police action, with due regard to the safety of the ward environment Inform Managers and document all observations and actions Discuss with RMO/on-call Consultant Discuss with MDT where possible Possible Police action after consultation with RMO/Managers With regard to alcohol, it will be made clear that alcohol is not permitted on the ward and will be disposed of Document that the Service User has been informed of the above 8.3 If a visitor is supplying drugs/alcohol (staff will have observed the act): The Policy and Procedure will be explained to them and they will be made aware that this is unacceptable/inappropriate behaviour They will be asked to leave and take the substances with them. If they refuse to leave, they will be informed that the Police will be asked to attend. If the visitor has been supplying illegal drugs, the nurse in charge of the ward will inform the Police and the Manager will be made aware of the incident The MDT will consider whether future visits will be permitted All incidents will be recorded on the incident reporting form If the visitor is a Service User, their Care Co-Ordinator will be notified. The visitor should be informed that this will happen. 8.4 To assist in ensuring that everyone is aware that alcohol and substance misuse will not be tolerated, the poster at Appendix 2 must be displayed in all premises that Service Users use. Page 5 of 11
Community Settings 9. Suspicion of Substance Misuse Initially it is important to consider the reliability and source of the information Consider the impact that the use of drugs/alcohol may have on the Service User s Mental Health and the need for extra vigilance as a clinical issue. Discuss this with LPT Substance Misuse services if advice if needed Record the incident in the case notes and inform all people involved in their care 10. Awareness of Drug/Alcohol Use Staff will have witnessed the act of using substances and/or the Service User will be intoxicated If there are concerns about the Service User s mental/physical condition, consider the following potential courses of action, but these should only be considered following a risk assessment to establish whether the staff member is safe to carry out the following. Consideration should also be given as to whether a referral to Child Protection agencies is necessary if there are children in the household: 1. Harm Reduction. Discuss the issue with the Service User and educate them about the impact of drugs/alcohol on their Mental Health (see Appendix 3). 2. If concerned about deterioration in Mental Health, then discuss with the Service User the possibility of the safe disposal of the substance. Staff should only remove substances in exceptional circumstances and only after consultation with the appropriate Manager. Substances should be disposed of responsibly as per Appendix 4. The Manager will take the necessary steps to ensure that any action remains within the law (eg consult with the local Police or take legal advice) 3. If the staff member considers they may be at risk they should withdrawn from the situation immediately. All people involved in the care of the Service User should be informed as appropriate If the Service User is not currently involved with Substance Misuse services, then they should be encouraged to access treatment from the appropriate service. The notice as per Appendix 2 should be displayed in community settings Page 6 of 11
Appendix 1 PROCEDURE FOR THE MANAGEMENT OF CONFISCATED DRUGS In-Patient Setting With a staff witness, seal the substance in a clear plastic bag. Both staff must initial the sealed bag. Gloves should be used to handle the substance Contact the pharmacy staff and ask for the substance to be collected/removed/stored prior to disposal. The pharmacy staff will contact the Police to have the substance removed whilst maintaining patient confidentiality Store in the controlled drug or other locked cupboard until collected. The substances should be registered in the controlled drug register under unknown substance and should be signed out in the usual manner for controlled drugs by the visiting pharmacist The substance will be stored in the pharmacy department and a record will be made in their controlled drug register of where the substance came from, but not the Service User s name. The controlled drugs/illicit substance will be destroyed in the present of a police officer. Where the substance is in used or unsheathed injecting equipment, staff should refer to the procedure for safe disposal of injecting equipment or other sharps Record the incident using the Incident Reporting Form, the relevant nursing notes/care records and inform the bleep-holder and any relevant Line Manager If a patient is found to be in possession of needles that they use for taking illicit drug, these should be removed and permission sought to dispose of them. These could include discharge of the patient or initiating a search of the patient and the removal of such objects that could pose a danger to others. Items such as needles which may pose a Health and Safety risk to either other patients or staff should be safely disposed of in the sharps container regardless of whether the patient is agreeable to this. A record should be made in the patient s notes. In the cases where needles are handed or in removed from a patient then the individual should be furnished with the current list of pharmacies taking part in the needle exchange scheme where they can get a supply of free, clean needles. Further details about the scheme can be obtained from the Substance misuse Team or pharmacy. Page 7 of 11
Appendix 2 ILLEGAL DRUGS The use, production or supply of illegal drugs will not be permitted or tolerated on these premises Anyone found or suspected of breaching this rule may be banned from the premises for an indefinite period and their details passed to the Police Please Note: Passing, sharing or swapping illegal substances constitutes supply under the Misuse of Drugs Act 1971 Page 8 of 11
Appendix 3 DRUG EFFECTS AND WITHDRAWALS Opiate Drugs (heroin, morphine, methadone, dihydrocodeine, buprenorphine) Possible Effects: Opiates are analgesic drugs Euphoria Warmth Relaxation Removed feelings of anxiety Larger doses may cause sedation/sleep If long term User, then taking opiates help to take away opiate withdrawals Unlike other depressant drugs, doses sufficient to cause euphoria do not impair movement or intellectual ability Possible Withdrawal Effects: Weakness Yawning, sneezing Sweating Goose bumps Insomnia Aches and pains Abdominal cramps Nausea and vomiting Diarrhoea Stimulant Drugs (cocaine (crack), amphetamine, nicotine, caffeine) Possible Effects: Stimulants are excitatory drugs Increased energy Feelings of exhilaration Increased confidence Increased ability to concentrate All leading to an overall feeling of increased capacity to do work, great physical strength and mental supremacy Page 9 of 11
Possible Withdrawal Effects: Irritability and anxiety Decreased mental energy Fatigue Feeling low in mood Benzodiazepines (diazepam, temazepam, nitrazepam) Possible Effects: Benzodiazepines are depressant drugs Relieved anxiety Increased confidence Feeling disinhibited Impaired judgement Sedation Possible Withdrawal Effects: Restlessness Agitation Sweating Tremor Hallucinations or illusions Possible fitting Alcohol Possible Effects: Alcohol is a depressant drug Feeling disinhibited Relieved anxiety Impaired judgement Lack of co-ordination, blurred vision, slurred speech Sedation Possible Withdrawal Effects: Sweating Increased hand tremor Insomnia Nausea and vomiting Agitation and anxiety Visual, tactile or auditory hallucinations or illusions Possible fits Page 10 of 11
REMOVAL AND TRANSPORT OF DRUGS FROM A COMMUNITY SETTING Appendix 4 The Trust does not routinely expect its staff to remove illicit substances from Service Users in community settings. A decision to do so should only be made in exceptional circumstances where the safety of the Service User is a major concern and there are no practical alternative methods of disposal. Staff should place the substance in any available container (eg envelope) or wrap the substance carefully A receipt should be drawn up showing the following details and signed and dates by both/all parties: Description of contents as unknown substance The number and colour of tablets if applicable, or The number of blocks of resin if applicable, or A brief description of the substance(s) and number if not in above The container or envelope should be sealed if possible and made safe in a locked brief case if available Transport of the substance(s) to a safe place should be an urgent priority. The legally recognised places of safety are: Pharmacy Ward Police Station If staff feel more comfortable, they should telephone the local Police Station and inform them of the intended arrival and purpose. The action supplies legal cover whilst the drugs are in transport in their possession If the drugs are brought to the pharmacy, staff have the same right to inform Police they have illicit drugs in transport for handing over to a designated place of safety Staff should wait at Pharmacy until all the relevant paperwork has been completed If the drugs are returned to one of the Mental Health Wards, the member of staff should personally oversee the recording and controlled drug procedure The case notes, drug incident form and the general incident form should be completed at the earliest opportunity Page 11 of 11