Problems (Dual Diagnosis) Strategy 2016-18 Board library reference Document auth Assured by Review cycle P154 Consultant Nurse f Dual Disder Quality and Standards Committee 3 Years This document is version controlled. The master copy is on Ourspace. Once printed, this document could become out of date. Check Ourspace f the latest version. Contents 1. Introduction... 2 2. Philosophy... 2 3. Standards... 2 4. References... 4 5. Appendices... 6 Review date: 15/12/2015 Version No: 1.0 Page 1 of 10
1. Introduction The aim of this strategy is to ensure AWP mental health services deliver timely, compassionate and effective treatment f people with co-existing mental health and alcohol and drug problems. The term co-existing mental health and alcohol and drug use will replace the term dual diagnosis. However, these two conditions need to be considered within a wider framewk of complexity and need, and should include physical health, housing, vocation, financial, legal, spiritual and relational needs. This strategy builds upon AWP s previous co-existing mental health and alcohol and drug problem (Dual Diagnosis) strategies. It outlines an evidence infmed approach which should be delivered Trust wide. 2. Philosophy Evidence infmed principles cover the following areas of treatment. An integration of both conditions, a low stress harm reduction approach, the use of Cognitive-Behavioural strategies to teach me effective interpersonal and coping skills, suppting functional recovery, and engaging the social netwk. These interventions are delivered by practitioners who believe recovery is possible, thus instilling hope in clients, their family members and other treatment providers (Mueser, 2012). NICE guidelines f Psychosis With Co-existing Substance Misuse (2011) also highlights the imptance of not excluding people with co-existing conditions, seeking specialist advice and initiate joint wking f very complex cases, the need to challenge stigma, be culturally aware, engage with families and carers, be aware of the possible concealment of difficulties, be aware of possible safeguarding issues and use NICE guidelines f specific mental health and alcohol and drug problems (See Appendix 1) The management of co-existing conditions are best considered using a chronic care model; balancing therapeutic optimism f change within a recovery framewk against a pragmatic response that long-term treatments can be effective in managing, but maybe not curing dependency (McLellan, 2014). It is helpful f outcomes to reflect the nature of long term conditions and f treatments to include training in self-management skills through coaching and problem solving. The use of recovery capital is underutilised by mental health services. Clients and patients are not assertively referred to 12 step programmes (Dual Recovery Anonymous, Marijuana Anonymous, Narcotics Anonymous, Alcoholics Anonymous), SMART Recovery and peer suppt wkers early enough often enough. A key goal of this strategy is to consider mutual aid as part of care planning f this client group. 3. Standards These are the minimum standards which AWP mental health services will be delivering. These ce standards will infm locally devised quality planning and assurance mechanisms. These local plans will be suppted and monited by the Quality Leads and the Integrated Governance Meeting. This strategy is suppted by the AWP CPA Dual Diagnosis Procedural Document. 3.1 Ensure equity of access to AWP services f those with co-existing alcohol and drug problems Access should not be denied because of heavy chaotic alcohol drug use. A flexible assessment response should be delivered, which may include an initial assessment while the person is partly under the influence of alcohol and drugs. If assessment / treatment is not considered appropriate, then a clear rationale should be provided to the service user, with suppting guidance f the referrer. Review date: 15/12/2015 Version No: 1.0 Page 2 of 10
Standard: F all clients not to be refused an assessment because they are using alcohol drugs. 3.2 Complete an alcohol and drug assessment as part of the ce assessment Alcohol and drug use will be documented on RiO, and a decision made regarding if use is problematic not. The following should be recded f problematic use: types of substance used, the amount, route, frequency, pattern and duration of use, the impact on mental and physical health, risks associated with use, the service user s view of their use, and an assessment of physical dependency (evidence of withdrawals, time and amount of last use, previous histy). NICE recommends the use of the AUDIT as a screening tool (appendix 2). Standard: Documented evidence on RiO in assessment fields 3.3 Document interventions and a risk management plan as part of care planning and risk management if use is considered problematic using an integrated stage-wise framewk to deliver interventions Treat both conditions as primary. Equal consideration should be given to both mental health and alcohol and drug needs. Alcohol and drug interventions should be shaped by what the person wishes to do about their problematic alcohol and drug use. Underlying psychological and emotional stresss and triggers should be considered. Harm reduction, motivational approaches, relapse prevention, pharmacological interventions and exposure to those in recovery should be considered. A wking hypothesis of pre-contemplation, contemplation action stage should be recded on care planning f both mental health and alcohol and drug needs. A suggested tool f this the SOCRATES v8 (The Stages of Change Readiness and Treatment Eagerness Scale). Appendix 3 Standard: When alcohol and drug use is assessed as problematic, there is evidence of documentation in care planning and risk management. 3.4 Ensure each ward and team has a nominated dual diagnosis link wker. Their role should be suppted to maximise the care pathway between services, by building links with local alcohol and drug services, people in the local recovery community and other agencies who wk with complex needs. Role guidelines are available and local standards agreed. Each link wker should complete the UWE Dual Diagnosis module. Standard: Each ward and team can identify a named link wker 3.5 All staff wking within AWP should ensure they are competent in the recognition, assessment and treatment of all age groups with co-existing mental health and alcohol and drug problems. All relevant staff should keep up to date with their statuty and mandaty training requirements. Standard: Staff to have completed one of dual diagnosis training opptunities every five years (E-learning, wking with dual diagnosis, link wker training, AWP Conference UWE modules) 3.6 F all AWP services to promote a recovery focus and introduce mutual aid. F co-existing conditions this will entail both the maximisation of mental health and alcohol and drug recovery. Mental health services should expose individuals to people in recovery early and often. F alcohol and drug problems this should include peer ments and mutual aid groups. All teams should have contact details of people in recovery and should make assertive links. Review date: 15/12/2015 Version No: 1.0 Page 3 of 10
Standard: F each service to invite substance misuse peer wkers/those in recovery to talk to the team and have contact details available. 3.7 Suppt f families, carers and significant others affected by alcohol and drug use All services should engage with families and carers, listen to their perspective and involve, if appropriate and with the service user s consent, in all aspects of care planning and treatment. It takes on average 7 years f families to seek help and suppt f themselves. Services should provide infmation regarding suppt f family members in their own right. All teams should know contact details of local ganisations that suppt families. Standard: Families and carers of those with alcohol and drug problems to be signposted to relevant suppt services. 3.8 Local care pathway agreements F each Locality in AWP to agree its own care pathway between key services delivering coexisting care and treatment. This will include referral criteria, joint assessment arrangements, care reviews and a process to resolve differences of opinion. Standard: All AWP localities to have an agreed care pathway with local alcohol and drug service providers and key stakeholders who suppt alcohol and drug needs. 4. References CPA Dual Diagnosis Procedural Document The most significant NICE guidelines are: Psychosis with Coexisting Substance Misuse: Assessment and management in adults and young people (NICE, 2011) As part of this guideline, related NICE guidance includes Alcohol use disders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115 (2011) Alcohol-use disders: physical complications. NICE clinical guideline 100 (2010) Schizophrenia. NICE clinical guideline 82 (2009) Medicines adherence. NICE clinical guideline 76 (2009) Drug misuse: opioid detoxification. NICE clinical guideline 52 (2007) Drug misuse: psychosocial interventions. NICE clinical guideline 51 (2007) Alcohol-use disders. NICE public health guidance 24 (2010) Community-based interventions to reduce substance misuse among vulnerable and disadvantaged children and young people. NICE public health guidance 4 (2007) Naltrexone f the management of opioid dependence. NICE technology appraisal guidance 115 (2007) Methadone and buprenphine f the management of opioid dependence. NICE technology appraisal guidance 114 (2007) Bipolar disder. NICE clinical guideline 38 (2006) Violence. NICE clinical guideline 25 (2005) Review date: 15/12/2015 Version No: 1.0 Page 4 of 10
Other significant guidelines include: Care Service Improvement Programme (2008) Themed Review Rept 07 Dual Diagnosis Department of Health (2002) Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide. London. Department of Health (2006) The Management of Dual Diagnosis in Mental Health Inpatient and Day Hospital Setting Department of Health (2006) Models of Care f Treatment of Adult Drug Misusers Update Department of Health (2006) Models of Care f Alcohol Misusers Department of Health (2010) New Hizons Confident communities, brighter futures: A framewk f developing well-being, available at: http://tinyurl.com/communities Brighter Futures Department of Health (2011) No Health without Mental Health: A cross-government mental health outcomes strategy f people of all ages Groshkova T., Best D. and White W. (2013) The assessment of recovery capital: properties and psychometrics of a measure of addiction recovery strengths. Drug and Alcohol Review: 32(2) 187 194. Home Office (2010) Drug Strategy 2010 Reducing demand, restricting supply, building recovery: Suppting people to live a drug free life, available at: www.homeoffice.gov.uk/ publications/drugs/drug-strategy/drug-strategy-2010?view=binary Hughes, E. (2006) Closing the Gap: A Capability Framewk f Wking Effectively with People with Combined Mental Health and Substance Use Problems Listening to Service Users: Developing Service User Focused Outcomes in Dual Diagnosis: A practical tool (MHDU, 2010) Psychosocial interventions f people with both severe mental illness and substance misuse (Cochrane Review, 2012) Review date: 15/12/2015 Version No: 1.0 Page 5 of 10
5. Appendices 5.1 Appendix 1 Key priities f implementation from NICE guidelines (2011) Wking with adults and young people with psychosis and coexisting substance misuse When wking with adults and young people with known suspected psychosis and coexisting substance misuse, take time to engage the person from the start, and build a respectful, trusting, non-judgemental relationship in an atmosphere of hope and optimism. Be direct in your communications, use a flexible and motivational approach, and take into account that: Stigma and discrimination are associated with both psychosis and substance misuse Some people will try to conceal either one both of their conditions many people with psychosis and coexisting substance misuse fear being detained imprisoned, being given psychiatric medication fcibly having their children taken into care, and some fear that they may be mad. Recognition of psychosis with coexisting substance misuse in adults and young people Healthcare professionals in all settings, including primary care, secondary care mental health services, child and adolescent mental health services (CAMHS) and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely ask adults and young people with known suspected psychosis about their use of alcohol and/ prescribed and non-prescribed (including illicit) drugs. If the person has used substances ask them about all of the following: - The particular substance(s) used - The quantity, frequency and pattern of use - Route of administration - Duration of current level of use. In addition, conduct an assessment of dependency (see Drug misuse: opioid detoxification [NICE clinical guideline 52] and Alcohol-use disders: diagnosis, assessment and management of harmful drinking and alcohol dependence [NICE clinical guideline 115]) and also seek crobative evidence from families, carers significant others1, where this is possible and permission is given. Secondary care mental health services Healthcare professionals wking within secondary care mental health services should ensure they are competent in the recognition, treatment and care of adults and young people with psychosis and coexisting substance misuse. Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate mental healthcare because of their substance misuse. Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate substance misuse services because of a diagnosis of psychosis. Consider seeking specialist advice and initiating joint wking arrangements with specialist substance misuse services f adults and young people with psychosis being treated by community mental health teams, and known to be: - Severely dependent on alcohol Dependent on both alcohol and benzodiazepines Dependent on opioids and/ cocaine crack cocaine. Adult community mental health services CAMHS should continue to provide care codination and treatment f the psychosis within joint wking arrangements. Review date: 15/12/2015 Version No: 1.0 Page 6 of 10
Substance misuse services Healthcare professionals in substance misuse services should be competent to: recognise the signs and symptoms of psychosis undertake a mental health needs and risk assessment sufficient to know how and when to refer to secondary care mental health services. Inpatient mental health services All inpatient mental health services should ensure that they have policies and procedures f promoting a therapeutic environment free from drugs and alcohol that have been developed together with service users and their families, carers significant others. These should include: search procedures, visiting arrangements, planning and reviewing leave, drug and alcohol testing, disposal of legal and illicit substances, and other security measures. Soon after admission, provide all service users, and their families, carers significant others, with infmation about the policies and procedures. Specific issues f young people with psychosis and coexisting substance misuse Those providing and commissioning services should ensure that: Age-appropriate mental health services are available f young people with psychosis and coexisting substance misuse and Transition arrangements to adult mental health services are in place where appropriate. Review date: 15/12/2015 Version No: 1.0 Page 7 of 10
5.2 Appendix 2 This is one unit of alcohol and each of these is me one unit AUDIT How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? Scing system 0 1 2 3 4 less 2-4 times per month 2-3 times per week 4+ times per week 1-2 3-4 5-6 7-9 10+ Your sce How often have you had 6 me units if female, 8 me if male, on a single occasion in the last year? How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was nmally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the mning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt remse after drinking? How often during the last year have you been unable to remember what happened the night befe because you had been drinking? Have you somebody else been injured as a result of your drinking? Has a relative friend, doct other health wker been concerned about your drinking suggested that you cut down? No No Yes, but not in the last year Yes, but not in the last year Yes, during the last year Yes, during the last year Scing: 0 7 Lower risk, 8 15 Increasing risk, 16 19 Higher risk, 20+ Possible dependence SCORE Review date: 15/12/2015 Version No: 1.0 Page 8 of 10
5.3 Appendix 3 Link: F Full Rating Scales: http://casaa.unm.edu/inst/socratesv8.pdf Review date: 15/12/2015 Version No: 1.0 Page 9 of 10
Version Histy Version Date Revision description Edit Status 0.1 31 July 2015 Draft strategy RE Draft 1.0 15 December 2015 Strategy approved by Quality and Standards Committee HD Approved Review date: 15/12/2015 Version No: 1.0 Page 10 of 10