Addictive States of Mind

Marion Bower, Robert Hale, Heather Wood, Marion Bower, Robert Hale, Heather Wood

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780367323011
• eBook ISBN: 9780429910593
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This chapter, written by a psychiatrist working with people with severe and complex addictions, sets the scene. We are provided with a graphic account of the multiple problems—physical, psychological, social, financial—of someone with severe drug addiction, where sex working and the risks of pregnancy, infection, and assault compound an already challenging presentation. The personal history of trauma and abuse means that the patient requires highly skilled and sensitive management, and adaptations in service provision—such as no morning appointments—that respect the individual's lifestyle. The conflict for professionals is encapsulated in a brief description of the responses of Vanessa Crawford's patient group when asked what messages they would like to be conveyed to future doctors: don't prejudge us, treat us as individuals, give us proper pain control—and "don't trust us". Implicit in this is the recognition that they are in the grip of something that leads them to deceive, probably themselves, but also others—a wish to pervert a relationship to someone who is trying to help. Crawford conveys the importance of being knowledgeable, but not omniscient; of helping the individual to overcome the barrier of shame, which may lead to information being withheld; and the crucial contribution of a collaborative and coherent staff team in containing such challenging patients and in helping them to turn a corner towards recovery.

CHAPTER ONE
Challenges in a substance misuse service

Vanessa Crawford

This chapter, written by a psychiatrist working with people with severe and complex addictions, sets the scene. We are provided with a graphic account of the multiple problems—physical, psychological, social, financial—of someone with severe drug addiction, where sex working and the risks of pregnancy, infection, and assault compound an already challenging presentation. The personal history of trauma and abuse means that the patient requires highly skilled and sensitive management, and adaptations in service provision—such as no morning appointments—that respect the individual’s lifestyle.

The conflict for professionals is encapsulated in a brief description of the responses of Vanessa Crawford’s patient group when asked what messages they would like to be conveyed to future doctors: don’t prejudge us, treat us as individuals, give us proper pain control—and “don’t trust us”. Implicit in this is the recognition that they are in the grip of something that leads them to deceive, probably themselves, but also others—a wish to pervert a relationship to someone who is trying to help.

Crawford conveys the importance of being knowledgeable, but not omniscient; of helping the individual to overcome the barrier of shame, which may lead to information being withheld; and the crucial contribution of a collaborative and coherent staff team in containing such challenging patients and in helping them to turn a corner towards recovery.

Drug and alcohol (substance misuse) treatment services are delivered by both statutory and non-statutory services in the UK. Medical cover is largely provided by psychiatrists or general practitioners. Substance misuse treatment services in England have started to undergo radical changes, and this is set to continue. Under the current Coalition Government, services are being re-tendered, and partnership bids between the voluntary and statutory sector agencies are encouraged. Jobs are being lost, and, due to economics, specialism will be diluted in order to achieve the cost to win a tender. Addiction psychiatry as a specialism for doctors in training has become very insecure.

The 2010 Government Drug Strategy has at its core the theme of abstinence as the definition of "recovery". The Coalition Government set out the following goals for the drug strategy:

Reducing demand—creating an environment where the vast majority of people who have never taken drugs continue to resist any pressures to do so, and making it easier for those that do to stop. This is key to reducing the huge societal costs, particularly the lost ambition and potential of young drug users. The UK demand for illicit drugs is contributing directly to bloodshed, corruption and instability in source and transit countries, which we have a shared international responsibility to tackle;

Restricting supply—drugs cost the UK £15.4 billion each year (Gordon, Tinsley, Godfrey, & Parrott, 2006). We must make the UK an unattractive destination for drug traffickers by attacking their profits and driving up their risks; and

Building recovery in communities—this Government will work with people who want to take the necessary steps to tackle their dependency on drugs and alcohol, and will offer a route out of dependence by putting the goal of recovery at the heart of all that we do. We will build on the huge investment that has been made in treatment to ensure more people are tackling their dependency and recovering fully. Approximately 400,000 benefit claimants (around 8% of all working age benefit claimants) in England are dependent on drugs or alcohol and generate benefit expenditure costs of approximately £1.6 billion per year (Hay & Bauld, 2008, 2010). If these individuals are supported to recover and contribute to society, the change could be huge.

[HM Government, 2010, pp. 3–4]

East London Substance Misuse Services

In the area I work, in East London, there is a statutory service providing care to complex cases and the non-statutory service for those service users who may have lesser complexity. Complexity is defined by the level of problems caused by the drug(s) or alcohol used. This may be psychological, psychiatric, or physical and is usually a combination of all the above factors. An example of a complex patient would be a 30-year-old female, opioid-, alcohol-, benzodiazepine-, and crack-cocaine-dependent with tuberculosis and HIV, involved in the sex-working (prostitution) industry with a history of sexual abuse, depression, and suicide attempts. There will be some variation over time in the way patients are split between the two services depending on the skill mix of the teams and, to a lesser degree, on patient choice. In a low-patient-number, high-intensity service such as ours, clear throughput with care pathways into and out of treatment are essential to prevent the system clogging up. Patients may become very attached to one key worker or a system, and well-planned and transparent disengagement can alleviate a lot of distress in the patient. Initial engagement takes place over 12 weeks and may continue for years if the presentation is extremely challenging. The majority should transition into a service for more stable cases within months. Our service takes referrals from any professional, but predominantly referrals come from the local non-statutory sector community drug service and GPs.

At the Specialist Addiction Unit, we are commissioned to see case loads of approximately 30 per worker, and the staff group consists of psychiatric nurses, psychiatrists in training, sessions from a clinical psychologist, and the invaluable resource of a general nurse. We provide addiction treatment for any substance, prescribed or illicit, alcohol, and drugs. Our speciality is complex interactions of drug use, challenging behaviour, mental illness, physical health complexity, and hard-to-engage populations.

Substance misuse services are generally catchment area, based on borough of residence; attachment to registered GPs can cause problems as the area of residence may no longer match with the GP. This is important in that ease of access may significantly improve engagement in treatment; with a substance-focused lifestyle, short geographical distances can become huge barriers psychologically. Also, the funding for any residential or paid day programme will be paid by the budget holder only if the individual resides in the borough funding his or her treatment.

In many individuals, an addiction is linked with a desire for instant gratification, so delaying treatment may negatively affect engagement. However, instant treatment may only promote initial, but not continued, engagement. An excellent compromise is to make early telephone contact with a patient, explaining what the service can offer him or her.

Specific substances

I have focused on three of the most common substances. Easily accessible information for all other substances can be found on the Internet at DrugScope (www.drugscope.org.uk/resources/drugsearch/drugsearch-index.htm) and, for the ever-expanding catalogue of mind-altering chemicals, at Erowid (www.erowid.org). Erowid also provides a fascinating insight into personal experiences with named chemicals under their “What’s New” section (www.erowid.org/new.php).

Alcohol

For a detailed description of the Alcohol Dependence Syndrome, see Edwards and Gross (1976). The definition of alcohol dependence can be transferred to all other drug addictions; it is useful in understanding what dependence can involve:

1. narrowing of drinking repertoire (i.e., drinking in response to a large number of cues); also described as a stereotyped pattern of drinking
2. salience (prominence) of drink-seeking behaviour
3. increased tolerance to alcohol
4. repeated symptoms of withdrawal from alcohol
5. relief or avoidance of withdrawal symptoms by further drinking
6. subjective awareness of compulsion to drink
7. reinstatement of dependent drinking after a period of abstinence.

Follow-up by Edwards of alcoholics over 10 years found that 25% had continued troubled drinking, 12% were abstinent. The remainder had a patchwork of abstinence and troubled drinking.

For approximately 90% with symptoms of alcoholism and of de pression, the primary diagnosis is alcohol dependence. Up to 70% complain of mood dysphoria during heavy drinking, and there is a 10–15% risk of completed suicide with alcohol dependence. Symptoms of depression should abate after three weeks of abstinence; diagnosis of major depression reduced from 67% to 13% in one group of alcohol-dependent patients following detoxification (Davidson, 1995). Increase in alcohol consumption is more likely during relapse of bipolar affective disorder, potentially creating havoc in conjunction with already disinhibited behaviour.

Cocaine

Acute effects last about 20 minutes and include exhilaration and decreased hunger. Excessive use leads to an acute toxic psychosis marked by agitation, paranoia, and hallucinations that may be visual, auditory, or tactile. These include a sensation of insects crawling under the skin, known as formication. Cocaine can cause respiratory and cardiac failure. Chronic use can lead to tolerance or withdrawal symptoms (mainly dysphoria and fatigue) and to a chronically anxious state. Seizures, heart attacks, and strokes are not uncommon; the commonest cause of chest pain to be considered in males in their forties presenting to casualty is cocaine use.

Crack cocaine

The first hit is always the best. . . . I’ve never had anything like it. With crack once you’ve got that hit of the day, no matter how much you take you don’t get it back. If the rock is there, I can’t leave it, even though I don’t get anything off it. But you can’t just have one [rock] and leave it; you’ve got to have more.

[quoted in Crack and Cocaine in England and Wales; Home Office, 1992]

Crack cocaine is the base of cocaine powder, the latter being the hydrochloride of the substance; crack cocaine has a faster onset of action than the hydrochloride and wears off more quickly, promoting its image as a “greedy drug”.

Heroin

Oh! just, subtle, and mighty opium! that to the hearts of poor and rich alike, for the wounds that will never heal, and for “the pangs that tempt the spirit to rebel,” bringest an assuaging balm; eloquent opium! that with thy potent rhetoric stealest away the purposes of wrath; and to the guilty man, for one night givest back the hopes of his youth, and hands washed pure of blood. . . .

[de Quincey, 1821]

It is probably one of the most pleasurable experiences I’ve had. All the pain goes. All the anger is gone. I was lying on the sofa floating happily. It makes you feel safe and warm like being wrapped up in a blanket.

[Anon; quoted in Drug Scope, 2012]

Heroin is an excellent pain killer and is best viewed in those terms when looking at its role as a drug of addiction. It cushions the user: some become upbeat and more active, others slow down and worry less about day-to-day issues as if dissociated from the emotion of an event. It can be smoked, inhaled, and injected, and the purity varies considerably when buying from the street. It is often used in conjunction with cocaine; a combined injection is known as “snowballing” or “speedballing”. The addition of cocaine is problematic due to its action as an anaesthetic; this kills the pain and therefore may lead to damage to the veins, as any pain that would have been felt is numbed by the anaesthetic effect. Withdrawal from heroin, contrary to that from alcohol, is not physiologically life-threatening, but the treatment (e.g. methadone), when given to an opioid-naïve patient, is potentially life-threatening. Of note, the majority of those taking up heroin use will stop without accessing any treatment service.

Engaging with substance misusers

The NHS Specialist Addiction Unit in Hackney, East London, forms part of the Mental Health Trust and is based on a general hospital site. This has the benefit of reducing stigma in that individuals seen visiting the site could be there for any health issue. The biggest problem we deal with in terms of achieving good-quality treatment is attitudinal. This is largely outside the addiction services, but not exclusively. We were recently told we were “dumping” a seriously ill, alcohol-dependent patient in casualty. We had sent a junior doctor (the key worker) and a general nurse with the patient to explain the presentation. The same presentation of confusion and vomiting would not have elicited the same response if the patient had cancer. It is very clear that, as health care professionals, we have no right to withhold treatment on the basis of the cause of the condition. Unfortunately those with substance misuse problems are often denied compassionate, empathic treatment on this very basis. Equally there are many examples of good practice and excellent staff, but we must challenge colleagues who use their professional standing punitively on the basis of their personal beliefs. Our patients are highly unlikely to formalize complaints, some believing that it is their own fault, others that the system will close ranks, and therefore they are wasting their time.

I teach future doctors and spend time on issues such as stigma which cannot be learned so easily from textbooks. We talk about not allowing age, gender, social class, and religious affiliation from stopping them asking the patient questions: “I ask everyone these questions—they may not apply to you, but I don’t know without asking.” We have patients of pensionable age using opioids and crack cocaine, and you would not know by looking at them. We see people with religious affiliations that would condemn drug use who are addicted; it may then be even more stigmatizing for them to disclose, so we need to enable them to do so. I encourage the students to reflect on their own religious and personal beliefs. How does wearing Muslim dress affect the patient’s transference, is it useful to pre-empt this with a personal statement, and should health care professionals self-disclose when asked? Many of these issues will come up for young doctors starting work in a hospital setting. We discuss how they would respond if they have concerns about a colleague’s substance misuse; they have a range of resources available to them, rather than ignoring the situation, hoping it will disappear. The aim is also to instil an adequate knowledge level so that they can take a good drug and alcohol history and know how to treat alcohol and opioid withdrawal and signpost into further treatment. Brief interventions/comments can be very powerful and remembered; junior doctors may not realize how much positive impact they can have even just by asking about an issue such as nicotine addiction. These same themes equal apply to anyone working professionally/ therapeutically with a service user/client.

I asked some of our patient group what key messages they would like me to convey to future doctors. They came up with four themes of “Don’t prejudge us”, “Treat people as individuals”, “Don’t trust us”, and “Give us proper pain control”, which have been reiterated by those in recovery. I have been working closely with members of Narcotics Anonymous (NA) who come and talk to the students about their organization and their own life stories. This receives very good feedback, challenges stereotypes, and enables students to ask any questions before testing these questions out with “live patients”. They can ask questions in their group of about 50 students or come down at the end and ask questions individually. It enables students to also disclose family and personal issues and receive appropriate signposting advice from the consultant lecturer. It also forms part of the “work” of those in 12-Step (NA) recovery, and so it has a linked positive effect. In smaller group teaching on site, I favour the involvement of expert patients—patients already in treatment who feel able to speak to future doctors either alone or with a doctor as facilitator. Of note, students have said that one of the reasons psychiatry is unappealing to them as a career is that they do not see recovery. This may represent more than just seeing recovery, as oncology and many other areas of medicine will provide this same perception of little recovery. More community care has led to those being admitted to hospital being much sicker, thus feeding into this perception. Patients are discharged home earlier, and their recovery is not witnessed by medical students on the whole. Involving NA has been very positive in this respect as they are addicts in recovery, and I hope to be able to introduce this teaching earlier in the curriculum. There is a national medical student curriculum for addictions, and the plan is to ensure that this is embedded throughout the curriculum, as addiction touches on every system of the body and can be seen in all patient groups.

Building trust through a therapeutic relationship takes time, especially where there is a history of difficult and abusive relationships in a person’s life as a child or as an adult. Given the risk of staff changes over time, it is important to engender a therapeutic relationship with the service, rather than the individual, although both are very important. Ensuring that staff avoid repetition of questioning and have a good knowledge of the patient’s notes is to be developed within teams. Recently one of my new colleagues was faced with a patient’s concern that it would be necessary to start again after a change of key worker. The staff member’s duty is to reassure that holidays, sickness, and other changes should not affect patient care; we all have access to the patient’s notes and a duty to read them prior to seeing the patient. Listening, empathy, and unconditional positive regard are the attributes we would like all staff to develop. Sharing of case management in team clinical meetings enables all staff to look at different ways to manage complex and challenging cases while maintaining a positive therapeutic relationship. All staff are encouraged to keep patients apprised if they are running late and to apologize if this is the case. We have a general nurse on site every day, so delays allow a great opportunity to link the patient to the general nurse while waiting for the appointment with the key worker. We telephone patients during their appointment time if they do not at...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• SERIES EDITOR'S PREFACE
• ACKNOWLEDGEMENTS
• ABOUT THE EDITOR AND CONTRIBUTORS
• FOREWORD
• Introduction
• 1 Challenges in a substance misuse service
• 2 Parental addiction and the impact on children
• 3 Won't they just grow out of it? Binge drinking and the adolescent process
• 4 A neglected field
• 5 The deprivation of female drug addicts: a case for specialist treatment
• 6 Flying a kite: psychopathy as a defence against psychosis— observations on dual (and triple) diagnosis
• 7 Gambling: addicted to the game
• 8 The nature of the addiction in "sex addiction" and paraphilias
• 9 Anorexia nervosa: addiction or not an addiction?
• 10 In search of a reliable container: staff supervision at a drug dependency unit
• REFERENCES
• INDEX