Detox or long term stabilization

[brownbear67]

I ask this question as I am faced with a moral decision regarding my personal work ethics


Part of the new drug strategy is to move clients through drug treatment services as quick as possible from illicit drug use to abstinence, part of this work insist individuals are told from treatment start dates that they have 12 months to completed there treatment this includes substitute prescribing, those on high methadone maintenance doses already in treatment have also been told to detox over the next 12 months of treatment or face possible discharge?

 I certainly do not agree with this form of intervention, clients/people are individuals, and I feel if someone is highly functioning , not using on top of their script they should be able to choose weather or not they are ready to stop taking the medication, I feel at no stage should I impose enforced treatment!!?
 

[usandthem]

Hello Brownbear

Well that will be up to the Patient/Service User to decide.

The answer is a definite No. No DSP should have the right to discharge unless patient/service rules have been violated and patients refusing to be pressured off their meds is not one of them. You are right to be suspicious here. This service seems to be breaking all codes of practice according to NTA and NICE Guidelines UK. Please Read Professor John Strang's new updated Recovery orientated guidelines.

You will see that no such pressure should ever be put on patients in drug treatment UK. Plus how would that swing with those who co-use on top of their meds?! This service can do no such thing it is a violation of patient care and is ultimately breaking the law. The CQC and Department of Health ombudsman should be contacted about this service right away. Please contact The Alliance helpline in confidence. The links and numbers are in General Category Section, I think?

John

[Jules]

Welcome to the forum BrownBear.

As you probably know, we've had much discussion around the new drug strategy.  The Guidelines have not changed - nobody should be forced or coerced to reduce against their will.  Every service user should have a care plan agreed between them and their service provider/keyworker.

Recovery is being increasingly interpreted as abstinence as the only goal - as you will see from our regular posters, all of whom have their own individual aims, some for abstinence, some for maintenance but all for choice.  There should be no time limited prescribing.

How can we help you to resolve this within your service?  Please do call our Helpline or at least continue to post until you find some help with your dilemma and thanks for raising your concerns - it seems many in your situation feel unable to do so.  We do have a section for drug workers as you've probably seen.

Best wishes

Jules

[brownbear67]

Jules thanks for the kind welcome.
We do indeed follow a care plan approach, the issue I have is that at point of care planning service users are being advised that they have end options 3 months 6 months and 12 months in which to complete treatment, completing treatment means not using methadone any longer/detoxed

There are some exceptions, those that are considered complex needs!!  In the case that an individual is not able to detox in the time frame, he will obviously be extended pass the 12 month period once it has been agreed in clinical meetings.

There are very limited advantages to this approach if any, it may start to move some individuals through the treatment process that have been stuck in most cases through no thought of their own other than bad service provision or dare I say ,neglectful key workers!!

What I Have witnessed in the years of working in services is that quite often we fall in line behind political changes, and policies quite quickly without looking at effective practice, and we are very quick to abandon tried and tested methods, in the hope that what is new works, often neglecting to ask the very people that need the support.
Most service user surveys are taken from a very small sample of the number of service users, and not all DSP are connecting the needs of services users across boroughs and regions!

In my view we are reactive rather than proactive in provision, always trying to shift with what is new in terms of treatment provision, and in some cases this is done purely to keep a talon connected to the funding source.

 John , thanks for the link to Strands update will make interesting reading.

[Jules]

I understand your problem.  But surely the point of a care plan is that the S.U. discusses their treatment and potential aims - let's face it, not everyone knows at the start of treatment, they may be over-optimistic or slightly negative.  They should NOT be advised ie: told that they have to attain abstinence within a certain timeframe.  You know that you are setting people up to fail, why can't those who run your service see this?

It certainly shouldn't be a minority who have complex needs that fall outside this ridiculous policy - please ask them to re-read the guidelines.  This isn't government policy, it's your service provider's interpretation of it.  It's an endless problem for us.

All the best
Jules

[froude]

Welcome to the Alliance Brownbear,

Im both angry but not surprised by this so called "Forced De-tox"that D.S.P's around the country are being told to start doing ,some are blatant and some are very good at talking the talk and by the time you have come from your appointment you have been coerced into taking a reduction or even actually de-toxing when they are not ready.The only outcome from this so called  time frame will be more people going through this kind of system,and then being de-toxed to be thrown out to the wolves to defend for themselves again.Crime like street robbery,burglary will be on the increase,you will be seeing the same people coming through the court system with Drug order's,as these people will go back to the same thing they were doing before they were put on treatment.This is a massive negative in my eyes and it should'nt be up to the D.S.P to put timeframes in place as you are setting yourself up for failure straight away,for some people it was easy to fall pray to the opiates and will be eay to come off but that is a minority,the majority of people who will be going through this "Forced De-tox"knowing at the end they are going to fail,just because of the time frame.We should have a choice ,sit down and have a talk with your Key and if your medication takes 5 weeks to come off or 15 years to come off, you as the person in treatment should have a say,now it looks like it will be taken off no matter what the circumstances may be.To be told to be Abstinant aswell is a kick in the teeth if you ask me.What is this going to be called the Abstinant based 3,6,9,12 month timeframe System.Personally Abstinance isnt for me but Choice is,I took to Methadone Maintenence and it has kept me from either being Dead in the street or a life sentance in one of her majestys Prison's,plus CHOICE,just to have choice in my life has stopped me from using opiates this has taken me 8 hard years to do this after 20 plus odd years of being a drug bin. If i was to be told that my years of drug taking will take 3,6,or 12 months of treatment and then i will be abstinant id want to bottle this up and sell it to the highest bidder.Hope you have a good christmas ,all the best Froude

[sapphire]

Hi BrownBear - nice to see some treatment workers posting!

A service users care plan MUST always be their decsicion< not whatever treatment modality is currently 'en vogue', as abstinence based recovery is at present.

I am sure you know from experience that enforced treatment is never successful, and could have serious consequences on the service user.

OD's are already on the increase, as many people are being forced off the treatment that saves their life.

As Jules has said, this isn't the government or the NTA's guidelines - it is your services interpretation of them, and this needs to be addressed.

There is a 'whistle-blower' link on this site for people working in social care etc, so you could potentially tell your local commisioners that the guidelines are being interprested incorrectly, and quite dangerously, anonymously.

The fact that you are even asking 'Should I impose enforced treatment', means that you know it's wrong, and of course you shouldn't do it, and neither should any other keyworker at your service. How can t ever be successful, it doesn't have the service users needs at the heart of it, it has money, politics and figures.

I really hope, for the sake of your patients, that you do not do this.

[angiesims AKA true grit :)]

How can they expect to treat all SU's the same. If like me i had used drugs for 20 + years there is no way you could do it in 3-12 months. The stress and worry alone would push you! My last stint on MMT was for 10 years and for last 3 years have been bullied and pushed into detoxing. Yet I did it on my own without the medication they gave me. Now 6 weeks clean of everything and they don't want to know. My final care plan was done a week after over the phone! Job done in their eyes. Another statistic. Yet I did it without them! I think only them terms could be used for someone who has been using MAYBE a few months, BUT even then everyone should have individual care plans. And MORE SO AFTER-CARE! Good to see someone in that sector that actually cares 

[derek d j]

Let me join the above members in welcoming you to the site. Our concerns are your concerns, and we're all looking for the solutions.

Are you and like minded colleagues able to raise your reservations at in-house meetings? Or is there a feeling it may damage your chances of professional advancement to speak out?

The 'encouragement to abstinence' idea contradicts addiction realities and, as such, doomed to failure. When this becomes apparent to all involved, those able to say " I told you so " may be in pole position to determine future policy.

Am I right to think you've a 'Voluntary Sector' employer, Brownbear? If so, and you've previous NHS experience, what differences do you find between the respective regimes?

[brownbear67]

Thanks for your warm welcome.
I do not think it is important to say whether I work in non-stat services voluntary sector, they are all very blurred these days, it’s not about who provides effective services its more to do with cost effective services, unfortunately commissioners try their best to give balance when re configuring services but quite often there final choice of provider is 9 out of ten times based on reduced costing!
I have worked across both sectors and what is quite obvious is that within the statuary sector, i.e. NHS and local authorities, there tends to be very few professionals that have come from a using back ground.
In the voluntary sector they are more likely to have voluntary workers who were previous service users in some shape or form in the past; also voluntary sector services are very proactive in recruitment and encourage service users to go into care work.
 To be honest I have seen very poor standards of service in both environments, as well as some excellent standards.
One of the hurdles of doing voluntary work in NHS services is there tied up in bureaucracy regarding CRB checks and confidentiality, this stops them in most cases taking volunteers. Most prescribing services in the London area are no longer delivered by NHS services alone, a lot of the providers now work in partnership with the voluntary sectors, such as CRI, WDP, Addaction and so on.

Provision will change over the coming 12 months or so as health services re gig budgets enforced by the new governments unfair and unwanted cuts, this will further diminish the level of services available across the sectors  putting those in the most need at further risk.

What’s unfortunate over the years is that the vast majority of services users do not engage with service user forums, and service user meeting. Commissioners really value the input of service user and what they say really matters when it comes to re-commissioning and developing new services, so like I previously mentioned service users need to become involved in all aspects of their care including shape the pace and type of change!!

sorry about the long reply.

[simon]

I don't think commissioners do care what service-users think and engage with them in a box ticking excercise. Patients can be reassured they are being cared for by the cheapest bidder.

[brownbear67]

For instance if you have 2000 service users in a London borough and only 15% complete surveys, generally less than this,  and only 1-2 % are involved in organising service user forums then you have to except that the minority advocate for a majority, a bit like government!!

[usandthem]

This is the trouble with recruiting Pro-active ex-service users. Too often they base others recovery directives on their own experience of getting through treatment. In other words a pro-active ex-user may think that because completing the road to abstinence was their ultimate goal - then they should also expect similar results from other service users they are working with. This will make it very difficult for them to grasp an understanding of the service users needs and goals. Choice is automatically taken away from the service user.

Another way of looking at it is - Some service users will look at being in long term maintenance as a success, which if they are not co-using, is a success. Where as the Pro-active ex-user in a voluntary role as drug worker may see this as not being successful and will use their own history of seeking abstinence as a blue print for, or to justify, how other users should go about reaching those same goals.

 This is flawed and will be counter to working together for the well being of a users needs. The last thing the user needs is more pressure when the care plan hasn't been met. Treatment for addiction, be it medically assisted, or psycho-social treatment, should be worked around the users needs. It is vital that treatment options remain open as individual needs are all different.

The treatment plan and goals, as long as it falls within the guidelines, will be worked out on arrival between: service user/worker/service, but should be completely owned by the user. There should be no timelines. The service is there to support the medically assisted recovery but not to intervene on the users treatment plan unless, either, there is a risk of death, or a danger to staff or the public, or directed or asked to do so by the user, and a decision will be made between the prescribing doctor (mandatory), the service, care worker and the service user only. Again you are following the needs of the user when making medical/clinical decisions. Of course Brownbear69 and other carers know all of this as they are mostly well trained, but they are trying to fathom the craziness of how some services conduct themselves in a manner contrary to that of the guidelines set out by the National Institute for Clinical Excellence. I was also just outlining some things to throw up on this thread for posterity purposes.

Here is me, John, Wishing a Merry Xmas to all who post on This Forum  

[derek d j]

Let's examine the reality of the dsp dynamic for a moment.

Some service users know they want off, some prosper on maintenance, the majority aren't really thinking too much ahead. Once a fortnight or month, they attend an appointment with a lowly paid 'key worker' of limited educational achievement and, with rare exception, little or no personal drug experience. Boxes are ticked and advice passed on according to policy.

Present policy is to encourage abstinence. The user 'silent majority' are primarily concerned with passing their 'tests' and where they'll next score. If the key sells the policy well, they make agree to 'reduce'. Then they go to score. Many spend as much or more on 'crack' than on heroin and may drink as well. For such users, the 'scripts' Treatment provides form only a part of their drug intake. It is unlikely they know anything of treatment politics, or are attracted to the idea of 'user groups'. If they 'change' it will be for reasons outside of treatment and the subject occupies little of their thoughts.

You may ask, to coin a phrase, what is point? What do these expensive organisations achieve that a GP could not? Other than 'group activities' for those wanting to 'get clean' in company, keeping their staff off the dole and maintaining the illusion the government is 'sorting it out', can you think of anything?

The 'drug problem' exists because 95% of drug users, in or out of treatment, are involved with the black market. For every 'successful discharge' there are two new faces on the corner. There will be no change until 300,000 drug outlaws are brought in from the cold. Only a wider prescription base - a return to some variation of Rolleston - will achieve this and check the power of drug black marketeers. Conversely, turning dsps into rehab annexes will increase it.

At the moment, drug treatment and problem seem to exist in separate universes. Treatment can only survive by acting as if what happens beyond its door is not its concern, which is plain ridiculous. We cannot pretend the present set-up offers any challenge to vast criminal enterprises or there are not 300,000 hapless, unnecessary criminals out there. Let doctors prescribe heroin and remove half the criminal power at a stroke. Both user and specialist can focus exclusively on the pharmaceutical aspects of addiction; it will have the additional effect of a greater percentage 'kicking' sooner, as they did under Rolleston. Let 'help' agencies exist separately for those who want them. It's the only thing that makes any sense. Now try telling the commissioners.

A Merry Christmas to you, John, and all other contributors to this thoughtful little forum. Let's hope 2012 is the year sanity finally returns to UK Drug Treatment.

[sapphire]

Derek - your last post really does sum it up very nicely!

Merry Chrimbo everyone, as Derek Says, lets hope 2012 is the year that sanity returns!!