Substance Misuse and Appropriate Intervention - Essay Example

Substance Misuse and Appropriate Intervention College Substance Misuse and Appropriate Intervention Introduction There are intricacies involved in the understanding of substance misuse. Issues on patients, prescription, access to substances, and even laxity and improper intervention on the part of medical practitioners may be seen. This paper will try to explore issues about substance misuse, risks associated with it, prevalence, relapse, and proper treatment amidst the many approaches that have been explored for a while now. It will try to point out any debates on cause or relapse reasons as well as the role of the patient and persons surrounding him. Background One of the more pressing issues in health care intervention is the issuance, administration or prescription of drugs for patients. There has always been a continuing challenge about dispensation, dosage, supervision, as well as effect on patient so that medical practitioners, pharmacists, and their team have to be wary of several considerations prior to any action that relies administration to the patient or his / her immediate carer, or even in controlled setting. Reaction to drug or substance misuse vary leading to ideologically driven approaches in medicalization, treatment, decriminalisation, and even use of the criminal justice for quasi treatment. Other propositions such as harm minimisation and harm reduction were also considered with the understanding that use of substance is inevitable (Bevan, 2009). People with severe mental illness, group of individuals with complex needs and a varied range of problems are usually the concern for ‘dual diagnosis’ and co-morbidity related to substance misuse or abuse. It was suggested that many problems related to substance misuse are linked to ill-prepared services that deal with these conditions. Bevan (2003) observed that Public Health treatment for substance misuse should understand that those who receive treatment are of chronic and frequently relapsing condition. Perception of treatment should move away from an individualistic approach to an understanding of the many and varied relationships as part of treatment rationale. Focus should also be given on minimising the harm associated with drug use. Prescribing policies for opiate replacement should also be considered instead of abstinence as prescribed doses of methadone have demonstrated positive results. “The reduction in drug related deaths, as a result of the reduced frequency of accidental overdoses, and the wider population health gains when treatment and interventions are flexibly delivered is further evidence that the health of populations can be improved with public health based strategies for substance misuse,” (Bevan, 2003), P 19). People should not be seen as failures when relapse occur for substance misuse. Various conditions influence substance misuse and these should be taken as a whole and not in part to fully understand the patient as well as provide a more effective and holistic intervention approach. Likewise, Bevan (2009) noted that curing should not be the focus as an over emphasis on moving people on, through and out of treatment usually results in the revolving door phenomena. Substitute prescribing has been offered a possible solution to address issue on substance misuse. Engaging the individual as member of a wider society and members of dynamic social groups with families, friends and acquaintances should be a public health consideration in addressing this issue (Bevan, 2009). Substance Misuse and Problematic Drug Use Problematic drug use and misuse occurs when individuals experience a range of unwanted and negative consequences as a result of their drug use (Brown, 2007). Problems may be social, psychological, physical or legal resulting from regular or excessive consumption, intoxication and/or dependence on any substance. The National Treatment Agency for Substance Misuse (2002) observed that these individuals often attempts to achieve stability or abstinence but relapse is usually a problem. The problem drug use has also been described by the World Health Organization (WHO) as a chronic behavioral disorder where control requires many attempts and relapse is common resulting to a repeated cycle of treatment, relapse and recovery (Bevan, 2009). Chronic & Relapsing The Royal Pharmaceutical Society in the UK suggested that crisis or relapse are symptomatic during treatment for problem drug use thereby recommending a recognition of the problem as chronic and relapsing (Levy, 2008). Relapse prevention should deal with obstructive and negative beliefs that lead to repeat behaviours. These include negative emotions, negative physical states, urges and cravings, and inter-personal conflicts. Attempts should be made to better understand why relapse occurs and what preventative measures can be used to enable patients to move forward (Bevan, 2009). The Royal College of General Practitioners in the UK suggest that substance misuse should be treated as any chronic condition managed in Primary Care. Aside from cure, effective management of the condition should be the goal and that symptoms should be ameliorated. Patients and service users should strive to recognise causes of episodes of relapse to understand of problem drug use (McEvoy P, Barnes, 2007; Bevan, 2009). Among patients with long term conditions, there is the prevalence of poor compliance and limited adherence to treatment plans and advice with complex reasons for non-compliance. The client and the health care professional should focus on the same perspectives and if necessary, define and aspire for negotiated goals (McEvoy P, Barnes, 2007; Bevan, 2009). Compliance can best achieved through a working relationship based on a shared understanding of the issues, how these issues can best be addressed and understanding why people default from optimal treatment (Bevan, 2009). Chronic and relapsing condition should not be placed as a client or patient’s choice but instead, a cooperative endeavour should be a goal to control the situations and circumstances. Non-completion reasons should be identified when patients stop the medication because they feel better or because the prescribing regime was too onerous or complicated to fit in with a normalised life style (Meier, Barrowclough, and Donmall, 2005). Patients should be motivated to complete treatment through an understanding of its beneficial outcomes but sufficient motivation has been seen as a challenge (Bevan, 2009). The concept of substance misuse is often linked to individual with a combination of psychiatric disorder, substance misuse disorder such as depression and alcoholism, and to specific severe mental illness such as psychosis, schizophrenia and substance misuse disorder such as cannabis abuse (Afuwape, 2003). However, it may also relate to a population with co-occurring addictive and mental disorders (COAMD), mentally ill chemical abusers (MICA) and chemically addicted mentally ill (CAMI) (Afuwape, 2003). Dual Diagnosis The term dual diagnosis has also been associated to two over-lapping but separate groups of individuals that misuse substances: a subgroup with both major substance disorder and a major psychiatric illness and another subgroup of substance users that affect the course and treatment of the mental illness (El Guebaly 1990; Afuwape, 2003). Other classifications of individuals with dual diagnosis associated with substance misuse are those with: primary mental illness and substance misuse of which the symptoms of the mental illness lead to drug use; substance misuse with psychiatric progression, which substance use or withdrawal from substances causes symptoms of mental illness; dual primary disorder, whereby the substance misuse disorder and the mental illness are initially unrelated and can interact to worsen each other, and; common aetiological group, in which underlying factors such as homelessness as a risk factor for both depression and substance misuse lead individuals to both conditions (Lehman, Myers, & Corty 1989;Williams 2002, Afuwape, 2003). Prevalence The Epidemiological Catchment Area Study conducted in the United States assessed how common dual diagnosis occurs. It found that 47% of the people they surveyed with schizophrenia had substance misuse disorder at some time in their life. There is also high probability of a substance misuse disorder amongst patients with psychotic illness as compared against the general population (Kessler et al, 1994; Regier et al, 1990; Afuwape, 2003). Another study conducted by Drake et al (1998) examined the extent of substance abuse in a group of 187 chronic mentally ill patients living in the community. Aided by clinicians, Drake et al (1998) found that about one third of the sample abused alcohol, street drugs, or both during the six months before evaluation (Afuwape, 2003). In the United Kingdom, studies have shown slightly more moderate rates of substance misuse among individuals with severe mental illness (Cantwell, 2003). In a study conducted in 2003, it found among 316 individuals with schizophrenia that 7% had reported problematic drug use in the year prior to being interviewed and 21% had reported problematic use some time before that (Cantwell 2003; Afuwape, 2003). In a study of individuals with psychotic illnesses who had been in contact with services in the London Borough of Croydon over the previous 6 months, Wright et al identified cases of alcohol or substance misuse and dependence through standardised interviews with clients and keyworkers. Prevalence rates of dual diagnosis were 33% for the use of any substance, 20% for alcohol misuse only and 5% for drug misuse (Wright et al, 2000).35% of the sample also indicated a lifetime history of any illicit drug use (Wright et al, 2000). Theories of dual diagnosis Due to the identified relationship between dual diagnosis and substance misuse, this paper will explore further the dual diagnosis theories. Mental illness-substance misuse relationship co-exists and the following theories attempt to explain the relationship (Mueser et al, 1998): Self medication theory Proposed by Khantzian (1987), this theory suggests that people with severe mental illnesses use of a particular substance to relieve or counter a specific set of symptoms or negative effects of anti-psychotic medication (Khantzian 1997). Substances are chosen for their unique effects such as stimulants (nicotine or amphetamines) to counter sedation caused by high doses of antipsychotic medication. ‘Alleviation of dysphoria’ theory Individuals with severe mental illness also experiencing dysphoria (feeling bad, anxiety, depression, boredom and loneliness) lead them use psychoactive substances to alleviate these feelings (Pristach & Smith 1996). Multiple risk factor theory Mueser, Drake, & Wallach (1998) suggest ‘risk factors’ such as social isolation, poverty, lack of structured daily activity, lack of adult role responsibility, living in areas with high drug availability, traumatic events such as sexual abuse, and association with people who already misuse drugs as factor in substance misuse. The supersensitivity theory Some individuals with severe mental illness have biological and psychological vulnerabilities caused by genetic and early environmental events in their life. When these vulnerabilities interact with stressful life events, it can lead to a psychiatric disorder or a relapse in an existing illness (Mueser et al, 1998). Anti-psychotic medication can reduce the vulnerability, but substance abuse may increase it and individuals may be less capable of sustaining moderate substance use over time without experiencing negative symptoms (Mueser et al, 1998). Factors associated with dual diagnosis Dual diagnosis is a focus on substance misuse due to poorer outcomes aside from increased severity of symptoms and relapse; frequent hospital admission; costly treatment; commitment of an offence or hostile behavior; suicide; increased rates of homelessness and insecure housing; more contact with the criminal justice system; increased risk of HIV infection; family problems or problems with intimate relationships; isolation and social withdrawal; greater levels of unemployment; and increased risk of poverty (Afuwape, 2003, P7). Treatment and Interventions Models of treatment Three types of treatment model include: Serial treatment models involve treating one condition first such the alcohol dependency. This is followed by treatment for the other symptoms such as the affective disorder parallel and integrated (Afuwape, 2003). Problems occur on this approach due to labeling one as more serious than the other when mental illness and the substance misuse are possibly mutually interactive and complicated further by equally pressing issues such as social isolation, unemployment, housing problems(Afuwape, 2003). Parallel model treatment focus on both mental illness and substance misuse simultaneously but delivered by two separate agencies. The challenge on this model is that the responsibility to communicate with the two teams often lies with the patient (Afuwape, 2003). Integrated model is an development of the parallel model in that mental health and substance misuse treatments are delivered concurrently. Treatments are delivered by the same staff member, or team of clinicians, in the same treatment setting (Afuwape, 2003). A study by Drake et al (1998) in the US showed that on the whole, integrated approaches are more successful in reduced hospital admission, clients’ overall symptoms, social problems and improved engagement and the Royal College of Psychiatrists (2000) recommend the approach. Treatment interventions may be any of the following approaches: Biological - Biological or medication treatments manages the substance misuse and the mental illness may be used to manage withdrawal symptoms caused by physical dependence on alcohol, opiates or prescription medication such as diazepam. This detox program is monitored closely for changes in mental state. An in-patient treatment is more preferable over a community approach (Afuwape, 2003). This is less applicable to be individuals with severe mental illness and alcohol misuse (Drake & Mueser 2000). Medication for severe mental illness often helps to control the biological disturbances underlying the illness by reducing anxiety, hallucinations, delusions, stabilizing mood or helping with sleep problems. Problem drug use treatment - An interventions that directly address or ameliorate the negative effects of problematic drug use. This may involve pharmacological interventions such as substitute prescribing and detoxification, thorough to psycho-social approaches including models of counseling and behavior modification (Bevan, 2009). “As important as the treatment and care is which directly addresses the problem drug use, focusing exclusively on these treatment interventions results in other drug use related issues such as sexual health, pregnancy, mental and psychological health falling outside the remit; the population's health benefits most from being addressed and managed from an inclusive i.e. public health and harm reductionist approach,” (Bevan, 2009, P 15). Bevan (2009) has further suggested that this method employing unhindered or unrestricted drug use has been beneficial although dependent on the controlled and supervised setting. Social and Psychological – This approach emphasizes on psychological principals and used for patients with mental health disorders and substance misuse. It engage individuals in treatment to prevent future relapse using several techniques as follows: Motivational Interviewing (MI): engages patient in supportive, directed conversation about the individual’s life events. It selects behaviours mutually agreed upon (Martino et al. 2002). Cognitive Behavioural Therapy / Counselling: This method weakens the connections between difficult situations and an individual’s negative habitual reaction to anxiety and substance use. The method is effective in improving alcohol issues and psychological functioning in individuals (Fisher, Sr. & Bentley 1996; Haddock et al. 2003). Family education: This approach involves the family members in the treatment plan to encourage patient as well as monitor medical regimen (Drake & Meuser 2000). Self-help groups: These are peer-orientated groups such as Alcohols Anonymous (AA) and Narcotics Anonymous (NA). They follow a 12-step philosophy in addressing substance misuse that helps individuals to complete medication regimens (Magura et al. 2002). Combinations of these approaches or the bio-psychosocial approach. In a dual diagnosis program, intervention may target symptoms of mental illness and inhibit substance misuse behaviors, family therapy and housing support to maximize motivation, encourage abstinence, and promote meaningful roles (Drake & Meuser 2000). Afuwape (2003) suggested that “A vital aspect of all the treatment approaches is the development and maintenance of the supportive therapeutic relationships that adopt a holistic approach to care and treatment,” (P9). Family Interventions The family is considered as non-treatment support that can contribute to the well-being of individuals with substance misuse problems. Aside from economic assistance or help with daily living, continuous care when treatment fails, and providers of the last resort, the supportive family can lay a major role in treatment (Clark 2001). But they should be careful not to exacerbate difficulties such that financial support could be used for substance purchase (Clark, 2001) Substitute Prescribing Substitute prescribing may be used as a harm reduction strategy. The dispensation of appropriate and safe higher doses of long acting opioids such as methadone are effective in reducing illicit opiates use, and in retaining problem drug users longer treatment services (Torres, 1996). Higher methadone doses assist drug users in using less illicit opiates. This method also applies better than pursuing an enforced abstinence. Morbidity accompanies drug users, particularly injecting drug users as studies indicated drug users are at a greater risk of premature death than their non-drug using contemporaries at 13-17 times greater (Hickman et al, 2003). Prescribed methadone maintenance is a protective factor against premature death of which longer term opiate replacement therapy “keeps problem drug users in treatment for longer and keeps those who are in treatment alive,” Bevan, 2009, P 18). Early and involuntary cassation of methadone treatment have also resulted to higher mortality rates as compared to retained treatment (Brugal et al, 2005). To sum up, substance misuse is linked with various health issues that includes primary focus of a public health approach to substance misuse in reducing harm among patients; understanding of the chronic condition characterized by poor compliance and limited adherence to treatment plans and advice; morbidity and mortality rates with premature deaths as a significant cause for concern; and support for substitute prescribing to address substance misuse among patients. Conclusion There are many factors and considerations in addressing substance misuse first of which should be on the unsupervised and unrecorded cases such as self-medication, among others. Measures should be undertaken to minimize these occurrences in order to fully support those who are in need of intervention. Intervention should focus on holistic approach that will not only address physical but also psychosocial issues of an individual who misuse substances. Pressing matters that induce use or relapse are as important as well as the misguided practice. Effective and less risky approaches such as substitute prescription should be considered as one of the most viable options to address substance misuse. Where dependence may occur, possibilities of shorter term interventions should be explored to further reduce costs and social implications of the problem. The role of medical practitioners and health care providers has not been fully explored in the misuse of substance debate. While this may be a case that missed by this research or not, it should hold an important space in the study of substance misuse. References Afuwape, Sarah A. 2003. Where are we with dual diagnosis (substance misuse and mental illness)? A review of the literature. Rethink severe mental illness. accessed at www.rethink.org/dualdiagnosis Bevan, Gez (2009). Problem drug use the public health imperative: what some of the literature says. 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