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Gurpal

Debate No.2 (May 2002) - Illicit Drug Use

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The people have voted! This month's debate:

Illicit drugs - to legalise or not to legalise? If you had to devise a national strategy to cope with the growing drugs problem, what initiatives would you introduce? On a more local level, how would you tackle the issue of illicit drug use on mental health wards?

You can be as politically correct/incorrect as you please!  ;)

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Legalise all the drugs, but tax 'em harder than petrol. The more dangerous the drug, the higher the tax, and the bigger the health warnings.

National strategy; drug advisory + Rx centres obviously, with general psychiatrists who have an interest in the area,(No further sub-specialisation of CCSTs thanks), with enough resources for primary prevention and early intervention, as well as the Mx of established problems.

Where will the money come from? The drug taxes of course, as well as a percentage of seized assetts from illegal (i.e. not paying their taxes) drug dealers.

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1. The big picture

First a few relevant details.

a.'illegal and drugs' are a 'modern' combination of words, the pronouncement of a rather hypocritical selfimportant civilization.

b. The americans tried prohibition and it led to criminal institutions that survive today.

c. Around 1% of the global GDP is spent in 'fighting' drugs.

The ethics involved here are those of paternalism. The state dose not alow its charges certain drugs but expects others to be used wisely. The distinction between some of these is seemingly arbitary. I wouldn't push the case with crack and nicotine but ethanol and cannabis are a reasonable pair.

So I suppose I agree with Fin above, max on the tax and let people pay for their mistakes.

There is a counter argument here given weight by those who have lost at the hands of drunken drivers; there may be some sunstances that will consistently cause misbehaviour in human populations. the question is what does society get and what does it pay for it?.

Here it is important to point out that the positive life enhancing effects of drugs such as ethanol are very rarely pointed out or explored. The vast majority of users may get more than they lose. Social lubricant, super ego solvent, sex aid and a salve for the difficulties of existing in a world that just dosen't seem to have ME as it's chief concern.

As for what to do on the ward, that is different.

No drugs. Urine testing. gaurd dogs. Searchlights.

etc.

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I suppose one useful way of looking at this is to review the social experiments that have taken place already.

1. In Holland particularly Amsterdam there are very relaxed drug laws and cannabis has been legalised. Drugs such as Heroin and Cocaine are still illegal. 2. In Singapore there are particularly strict laws regarding illicit drugs and the death penalty is given to those dealing in drugs. Drug use is almost minimal there.

In making a balanced judgement it would be useful to look at the statistics of those populations. For instance - lifespan, violence, crime, GNP, prevalence of depression/psychosis, HIV and so on.

I am ignorant of these details but would be most grateful if someone could look them up

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I am interested in different hospital policies for handling drugs on the wards. I have worked in units where patients have been marched off wards (regardless of mental state) by police and others where no action has been taken at all. Just what is the best way to go?

Elvis :-/

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drugs on the ward

Some patients are on wards  informally . This means  that they may leave and potentially take drugs and further return with them and distribute them.

It seems odd to me sometimes that those sectioned patients who can not leave at will and those informal live together on one ward.

If we are to do business all the substances being taken by the patient need to be medically prescribed.

So there are these people. They get treated at the same time as taking ilicit psychoactives. A very destructive untheraputic state of affairs.

The issue I think is about legitimate removal of capacity. The fact is that those deemed mentally ill lose a significant proportion of their freedom when they come into contact with mental health institutions.

Perhaps the next mental health act should contain a 'voluntary section'. It would be sort of a step bakwards but possibly necesary.

Or have only voluntary and involuntary wards.

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How hipocritical are we?

We slosh people full of mind altering, cognitively impairing and sometimes addictive drugs- leading to god knows how many RTA's, left on gas taps etc etc then we give people a good spanking for taking drugs at home.

I'm the first person to say that patients drug taking on a ward where people have drug induced psychosis and are detoxing is not a good thing however. Maybe we should have a ward drugs-spaniel/ pets as therapy animal and if a patient was found to have brought stuff on to the ward we should speak to them sternly and confiscate it (not for ourselves of course)

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quite a few hospitals ive worked in seen to think that drug taking on the wards is inevitable ,which makes anyone wonder whether any assesment of patient is drug free

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I am still none the wiser. Just how should we be managing patients who actively take drugs on the ward or who are known to be dealing? Maybe this is just a Merseyside thing but I doubt it...

Elvis ???

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I think if they are taking illicit drugs on the ward which are known to affect their mental state they should be booted out - [depending on the risk factors to the patients of discharge of course].

As a simple example supposing someone comes to you asking for help with their mood, you admit them and then find they are taking amphetamines on the ward. How rude is that. No there are clear boundary issues there - you need to just boot them out. They're being deceptive, they are a dangerous influence on other vulnerable pt's on the ward and they don't give two hoots about your effort to help them. They're sticking their two fingers up at you. If they are dangerously psychotic and still taking drugs you need to section them and not let them off the ward until they are much better. Give them one to one supervision at all times to ensure they are not receiving drugs off others etc.

Its not acceptable that this kind of use is going on on wards. One needs to stamp one's foot down. Boot them out and put clear guidelines stating that they should not be readmitted except under exceptional circumstances because of the extreme danger to other pt's. Indeed get them referred straightaway to another service - i.e. the drug and alcohol service where they belong.

In all honesty how many really sick patients are going to be using drugs on your ward. 60% of inpatients have PD's which is an absolute disgrace. If someone has a diagnosis of schizophrenia and they are using amphetamines on your ward its time to rethink your diagnosis.

Indeed if you let the PD's run the show on your ward what will happen is exactly what happened on one of my previous wards. The pt's said (to the taxi drivers) that the staff were great but some of the pt's were pulling a fast one (including the pt that told the taxi driver) and using the ward as a social centre for dealing, taking drugs, pulling other patients and getting a free ride on DLA. I will always remember that ward - in some respects it was so bad it was almost laughable. One patient had his room there for a year (acute ward). He furnished it, television, his artwork, radio, computer games. Every time he was ready for discharge he would say either he didn't like the discharge accommodation or that his hallucinations were returning. He would chip off at the weekends for some leave and take some cannabis at home. Another pt tried to use it as a doss house - every time he was intoxicated and a bit low he would pitch up at the ward. Others would be jacking up in the toilets. Indeed there was even a little signal for the local dealer - the patients would leave a handkerchief outside the unit and the drugs would apparently be delivered in the laundry.

If there were clear boundaries from the outset these kind of things just wouldn't happen. This is when the practising psychiatrist really needs to address transference issues - how much do they want to care for the 'needy' patient and how much do they want to deal with a psychiatric illness. Mind you it takes guts to say these things from the outset and you have to develop exceptional judgement to be able to do this safely. However clear protocols for difficult pts are often missing when it requires so little effort to come to a multidisciplinary decision about them and document them for the on-call team.

'Just say no' to drugs on the ward and get the police involved - [after all your in the best position to say if the drug use is secondary to their mental state or not]

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An absolute disgrace thats what I would say. Anyway I'm off to the pub.

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It seems the jury has come back more or less unnanimously. We should be the only people prescribing mind altering substances on psychiatric wards or the whole business is a bit of a farce.

A few more ideas.

1. very regular (weekly) urine drug screens for everyone.

2. a special 'drug and alcohol ward'.

3. legally binding contracts of some sort, although someone who is on a psychiatric ward may not be competent...

.. ok no real answers...anyone?

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I agree with pretty much all of the above. Talk is cheap, however. Contracts may make mental health staff feel better and in control but they mean jackshit at the end of the day and can not be legally enforced. The police issue is also more complex. Booting out Pd's, one could argue, is fair enough but booting out psychotic patients is a different ball game altogether. Far harder a practice to defend in terms of risk management.

Dual diagnosis seems to be like spinning plates and it may be that some level of drug use in some patients is inevitable. Perhaps we need to be realistic and accept that a proportion of our patient group use drugs. To say that, by using drugs, the patient is 'sticking his two fingers up to the psychiatrist' is maybe making the assumption that  the patient is rebelling against the psychiatrist when he probably doesn't really care and just chooses to use drugs. In this group of patients, are we really in a position to choose which of them we treat? It would be lovely if all our patients had nice lifestyles and nice lives but the reality is the opposite. And that is our bread and butter.

As for what to do on the wards, we do daily drug screens and keep those with drug problems on close obs. Still doesn't solve the problem of dealing or using while on leave. I guess our job is not to reject this patient group out of hand but to educate as best we can. Oh heck, there really is no easy answer.

Elvis :-/

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Yes there is

There are two possibilities

1. The pt is not capable of choosing to continue using drugs but does so anyway i.e. no capacity

2. The pt has capacity and chooses to use drugs.

I think the latter is almost always the case.

Its a decision, separate from the psychiatric illness.

Its just like choosing to walk up to someone and hit them in the face (when there is no psychiatric illness pretext for doing so).

Its their choice.

When they come of drugs its their choice.

We don't section drug users for drug use and detoxify under a section 3 for a good reasonThats because we have chosen to regard it as their lifestyle decision.

When a pt comes onto the ward and they are known to abuse drugs they should be educated and warned.

When they continue to use drugs on the ward they are showing a disregard for the education and efforts of the mental health staff caring for them.

Sure the mental health team get paid to do their work but its also their TIME and as such represents a part of their lives.

WAKE UP AND SMELL THE ROSES - if someone is abusing drugs on your ward and your spending a considerable amount of time trying to sort out their mental health problems it translates into - you are running around picking up the pieces after they have chosen to enjoy themselves. This is the bottom line with drug use - it is a selfish indulgence - a bit like pigging out on huge amounts of chocolate cake - except after that you don't think you can fly, or that your jesus christ or that you have been kidnapped by aliens and put back on earth for a special purpose.

These people clearly lack discipline and your not going to jolly well give it back to them by prescribing a few smarties and telling them how bad their life has been. They've got to sort it out themselves - your not going to do it for them - the boundaries were set decades ago (in the law and the psychiatric services) and for good reason.

There is a BIG BIG difference between illicit drugs and psychotropic drugs that are given to pts. With the latter the doctor is weighing up the risks and benefits of giving them and ideally would want the pt to get well without medication.

HOWEVER when the pt takes illicit drugs what exactly are the benefits for the patient's health??????

I don't understand why psychiatrists of all people would want to cloud these issues. In your practice you have to make a decision and stick by it. I think in this case things are black and white. Sure sometimes they are grey - but these are the EXCEPTIONS - and anybody with a bit of common sense will be able to identify these exceptions.

If you think it might be related to a psychiatric illness e.g. mania - treat the illness of course.

If there are some very sick patients who also choose to use drugs think carefully about the diagnosis but if it bears out - think very carefully about the placement - it will need to be very supportive and have very strict drug protocols. And don't for one minute think that if your tightening up the environment they live in so these poor souls can't have access to the illicit drugs everybody else in the population seems to use just remember one thing - they are ILLEGAL. You would be fully justified in having a strict protocol in the discharge accommodation - regular sniffer dogs, searches of rooms etc. This group of individuals has shown very clearly that they are vulnerable to many things but especially to illicit drugs. Start with zero tolerance and you can't go far wrong. Turn a blind eye to cannabis use and the next thing is that they are using ectasy once or twice and then speed and then cocaine and so on. I think this approach would be very effective but requires tremendous discipline on the part of the service. But in the end I think it would offer tremendous benefits.

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Some good points within quite a puritanical and judgemental rant. Can I be clear on just one thing? We SHOULDNT be treating patients who have mental illness secondary to drug use??! Where does that leave the thousands of dual diagnosis patients? Very dangerous territory. Wouldnt like to state that at an inquest... Respiratory physicians treat smokers, surgeons treat patients with vascular disease due to IV drug use etc etc. We cannot choose who to treat and who not to treat because a lifestyle choice offends us. We treat everyone the best we can. Idealist? Nope. Just a realist.

Elvis  :-/

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Here is Dr Prejudice returning for the amusement of all his fans.

I read a book of interviews with bigwigs in psychiatry. Don't ask me their names - I can't remember them.

Anyway one of them said this thing - i'll always remember this one comment

'mental illness is no excuse for bad manners'

How true is that. But you can modify it to

'Mental illness is no excuse for illicit drug use'

There 'nuff said'

Now if the courts come back to us what do we say. Simple really isn't it. We just say they are under the influence of drugs - there's nothing we can do at this point.

Now if you think about it that seems a bit of callous thing to say. But think real long and hard about it.

If your saying we should treat schizophrenic drug abusers any different from drug abusers without mental illness then you are PREJUDICED against patients with mental illness.

Only when you understand this will you understand the very deep statement above about 'mental illness is no excuse for bad manners'

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Whatever.  just believe all patients with mental illnes should be treated with the same skill and respect, regardless of their lifestyle choices.

Elvis ;)

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While I remember. The yellow journal issue last year that was all about cannabis and psychosis (Phil Robson from Oxford was one of the authors i remember) had a letter from an australian consultant explaining drug-seeking behaviour often being secondary to the psychotic illness e.g self medication. The above argument does not hold water in those cases nor for the majority of the many dual diagnosis patients we see every day. There is no black or white answer for this question because of these very points. To make sweeping generalisations implies a non-understnding of the dual diagnosis patient.

Elvis ;)

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So your'e saying that people with psychosis will self-medicate with amphetamines to treat their psychosis? Doesn't particularly make sense unless they want to make their hallucinations more vivid.

The point was addressed in one of my earlier replies.

Do they have capacity to take illicit drugs. If not - you have a duty of care to them to ensure they are placed in the right environment.

If they do have capacity then whats the problem? Are you saying that if someone has capacity, has schizophrenia and decides to take illicit drugs that that's OK. Schizophrenia is a terrible illness/illnesses and were here to treat it. But these people are still human beings and they are still capable of making rational decisions (if they have capacity).

In this above replies you are putting people with mental illness in a separate compartment to those without.

I would ask you to consider these questions

- at what point would you consider that a patient with a diagnosis of schizophrenia is capable of making an immoral decision which is not influenced by their mental illness?

- does a patient with a schizophrenic illness or other mental illnesses have responsibility for any or all of their actions?

- Does an antisocial personality disordered patient who abuses illicit drugs have a dual diagnosis?

If a member of the non-psychiatric population were found with illicit drugs they would be arrested and fined.

Shouldn't the default be the same for psychiatric patients?

In this case the onus would be on the psychiatrist to defend the patient on the basis of their mental illness. In such cases it would force the psychiatrist to consider the matter more thoroughly than if there were no penalties for the patients.

The law works because of negative reinforcement of undesirable actions. As a result the number of actions drops. This should include use of illicit drugs in the general population. If we automatically exclude psychiatric patients from this system then we are removing a very powerful form of control. If it was enforced it should reduce the level of drug use in the psychiatric population with a corresponding reduction in overall morbidity. The failure to do so is a direct result of prejudice against psychiatric patients which results in their increased use of drugs and subsequent morbidity and mortality relative to the general population.

I have put my case forwards and would be interested to see your arguments for why psychiatric patients who abuse drugs on the ward, or traffic on the ward should not be prosecuted.

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It certainly wasn't me who said that drug users should not be prosecuted. I would'nt have passed opinion as i have not formed an opinion. I have worked in trusts who have and have not arrested drug users on the spot and I am not convinced which was in the best interests or safety of the patient.

Also, while it may be true that drug use causes psychosis, it is also certainly true that some patients with severe mental illnesses self-medicate with illicit drugs in the same way as they do with alcohol. This might not sit well with the medical model or with doctors who take a paternal approach but it is well documented with heroin and cannabis (see aforementioned yellow journal).

In short, I have mixed views regarding the above. I would say that I have changed my views significantly since doing a dual diagnosis job. Some of what has been said here is just so black and white that it is largely irrelevant to the majority of cases. I would be interested to know which service would take over the care of these patients' mental health needs.

It is often so hard to separate whether the drug is the cause or the effect of the illness. With this in mind, a black or white style clinical management is clearly inappropriate. With dual diagnosis the approach is holistic and may have to resort to one of damage limitation. Yes this offends some practitioners who like neat and tidy cases but that's not real life. All patients are entitled to basic treatment regardless of lifestyle choices. As mentioned b4, surgeons amputate legs of IV drug abusers etc. We are doctors and our job is to treat. The law is not our business. The above posts imply that patients who use drugs with/without mental illness should receive little or none of our time. While this may be some doctors' subconscious wish, it doesn't sit well with the Hippocratic Oath.

As i said tho, I hold no strong views but do take exception to the kind of terms that have been bandied about in describing these patients such as 'immoral'. Since when have doctors been qualified to even discuss never mind label morality. I mean fgs.

I would be interested if there is anyone who can comment on their Trust policy of dealing with this increasing problem as I am flummoxed.

Elvis ???

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The word immoral was not meant to be used with drug use but rather to examine whether patients with psychiatric illness are capable of making important lifestyle decisions and I think the answer to this is obviously yes. It is their responsibility.

What I do not talk about is ignoring those with drug problems. Rather what I say is that if those people are on your ward they should categorically not be using drugs, bringing them on the ward, returning intoxicated or stoned, or dealing with them on your ward.

If you are going to treat somebody with a drug problem they have to be up front and tell you they can't hack it - that they are going to leave the ward and take drugs - then you discharge them. Doing otherwise is deceitful, is wasting everybody's time and is extremely damaging to other patients and is in short unacceptable.

In those cases I think the police should be involved.

The only cases where they shouldn't be is where there is diminished responsibility and this is I suspect where prejudice comes into the picture.

Also in this case are we saying that there is no way of treating patients. Nonsense - there is a forensic psychiatric service and there are also conditions of probation which would enforce treatment .

It is time to end the abuse of psychiatric services. It is time to end the pushing of drugs on the ward, the use of drugs and alcohol in inpatients, the violence against staff, the verbal abuse of staff. Give me one good reason why such abuse should be tolerated.

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Treating the mentally ill will always put one at risk of emotional trauma or indiferent calousness.

The fact that this debate seems to be so heated reflects society's ambivalence with respect to issues of Drug Abuse and volition and therefore the appropriateness of blame.

In a way the West is becoming increasingly proscriptive in it's expectations of individuals behaviour.

Note the PC brigade and there widespread influence.

Given this sort of control, social institutions such as ours are understandably uneasy assigning blame.

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Yes this is absolutely right. Psychiatrists are in one sense the social police. In terms of drug use probably the majority of the population between the ages of 18 and 25 have used illicit drugs at some point and would probably look at this argument as ridiculous. Indeed they would consider drugs to be part of everyday life. I suspect that is one of the reasons why there is a liberal attitude towards drug use in psychiatry - which I think is heavily influenced by the social norms [basically psychiatrists see thousands of patients each year and get a feel for what's normal/abnormal in the population in a kind of unconscious way. Hence the general consensus of the population filters through to psychiatrists in their practice]

But there is a big difference between everyday life and environments in which there are sick, vulnerable individuals and completely different norms need to apply in the psychiatric wards.

Interestingly these norms cannot be independent of whether illicit drugs are legalised or not. If they are legalised there is no recourse to involving the police. Discharging the patients also leads to difficulties over duty of care.

I think to get around this there should be special laws regarding the use of drugs and alcohol in hospital environments with possible fines or prison sentences. I think this would solve a lot of problems.

I mean for instance look at the amount of violence in hospitals especially in casualty which is on the increase. The relationship between violence and alcohol/drugs has been well established.

Laws that can be introduced include

(a) Pitching up at casualty intoxicated may lead to prosecution and would depend on a medical assessment of the risk/benefit of turning up at benefit

(B) Being a patient on a ward and taking alcohol or drugs whilst an inpatient can lead to prosecution after assessment of capacity has been made. This can be enforced after the person has improved and is fit for discharge.

If this sounds a bit over the top think of the number of intoxicated patients you have seen in casualty who have been facetious/threatening/violent/abusive and use the leverage of self-harm threats to manipulate casualty staff/psychiatrists. If they are admitted and found to have no evidence of psychiatric illness when sober they can be prosecuted.This whole approach would need to be developed over the course of time as specific cases are addressed e.g. Schizophrenic patients who turn up after using alcohol - using the justice system in this manner would ensure that fair protocols are developed which take into consideration the nature of the patient's illness and presentation. Using the justice system in this way is absolutely necessary as there is no satisfactory forum for debate in psychiatry which would involve psychiatrists across the country and which would result in changes of law.

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I'm with Elvis on this one. Booting out everyone who uses drugs on a ward is high risk and quite frankly avoiding solving the problem. Yes, ideally nobody would take drugs on the ward but the nature of psychiatry is that our patients are complex and present us with a range of management problems (that should be managed and not avoided by kicking them out...they'll only come back). Isn't that why psychiatry is interesting?

I think the analogy to medical conditions is a good one. If someone comes into hospital for treatment of their asthma and is caught having a fag and handing them out to another patient they wouldn't be kicked out.

I think its a similar issue to P.Ds. Drug addicts annoy us and are difficult so we want rid.

So how to manage?

Drawing up of contracts

Involvement of police when proven dealing

regular screens

empathic approach/ motivational interviewing/ look to solving the problem not avoiding it.

At the end of the day being kicked out is a last resort, and only then when the individual does not have a significant mental health problem.

Perhaps I'm just a big softy but just because patients can be a huge pain in the bum doesn't mean we should wash our hands of them.

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