Introduction to Dual Diagnosis in Assertive Outreach

Objectives

• Define and understand the term “dual diagnosis”

• Be aware of the prevalence rates in assertive outreach

• Be able to list associated consequences of having combined mental health and substance use problems.

• Policies relevant to dual diagnosis within AOT

Dual Diagnosis Capabilities

• Role Legitimacy: Recognise and accept that working with people with dual diagnosis is a routine part of ones role Dual Diagnosis Capability 1 level 2

• Acceptance of the Uniqueness of Each Individual: Be able to accept the person as a unique individual and respect their choices and lifestyle. Dual Diagnosis Capability 3 level 2

Definitions

• The term “dual diagnosis” is generally applied to people who have two disorders

• Combined mental health and substance use problems

• More than “dual problems”- likely to have complex health and social needs

• Wide range of people with varying degrees of need- need individualised treatment

Table 1

Serious mental illness

E.g. someone with bipolar affective disorderwho smokes cannabistwice per week

E.g. Someone with schizophrenia

and alcohol dependence

Minor substance use

E.G. Someone with anxiety who snorts cocaine

occasionally

Minor mental illness

Severe substance use

E.g. someone with heroin dependency and depression

“Mainstreaming”

DH (2002) Good Practice Guide:• Doesn’t advocate a separate specialist service for dual

diagnosis• Mental health services should take primary responsibility

for those with serious mental health problems (like schizophrenia) and substance use

• AOT likely to provide care for those with dual diagnosis as typically hard to engage and chaotic users of services

• Substance use services should take primary responsibility for those with primary substance problems and common mental health problems (anxiety, depression)

• However mental health and substance use services should work together and support each other

Discussion 1

What have been your experiences of working with people with dual diagnosis within AOT?

Think about issues concerning: – the individual – the carer– Yourselves– the AOT

UK Dual Diagnosis Prevalence Studies

• Menezes (1996) Inner London MH services 36% (1 year)• Cantwell (1999) Nottingham first episode psychosis 37% (1 year)• Weaver (2001) Inner London Community mental health and

substance use services 24% (recent-last 30 days)• Phillips (2003) Inner London (in-patient setting) 49% (last 6 months)• Graham (2001) Birmingham (MH and SU services) identified 24%

SMI problems with drugs/alcohol– More likely to be using at impairment/dependence level– More likely to be in AOT (26-45% of case-loads depending on location)– Over representation of African-caribbean in AOT (46%)

• Priebe et al (2003) London AOT 29% misused at least 1 type of substance(last 6 months)– 20% misused/dependent on drugs– 16% misused/ dependent on alcohol– Most common street drug was cannabis (23%), followed by cocaine

(7.4%)

Consequences of co-morbidity

• Increased likelihood of self-harm and violence• Poor physical health (including HIV, hep B and C)• Frequent relapse and re-hospitalisation• Higher rates compulsory detention• Forensic mental health care and criminal justice system• Higher overall risk of untoward incidents • Difficulty getting access to appropriate aftercare • Poor medication adherence• Family problems• Homelessness• Higher overall service costs• Higher levels of social exclusion

Profile Of Dual Diagnosis in AOT (London) (Fakoury, et al 2006)

• White*• Single • Young• Unemployed• Homelessness• Poor educational attainment• Living alone• Contacts with criminal justice system* (Graham et al (2001) found over-representation of people of African-

Caribbean origin in Birmingham, UK)

Most Commonly used substances

1. Alcohol2. Cannabis3. Cocaine

More rarely:– amphetamines– Opiates– Hallucinogens (LSD, magic Mushrooms)– Solvents and glue– Over the counter meds (anti-histamines)– Abuse of prescribed drugs (benzodiazepines, anti-cholinergics)

*NB geographical location will affect patterns- need to know your local drugs scene.

Patterns of use

• Use with impairment (DSMIV “abuse”) rather than dependence

• Poly-substance use common

Diagnostic Criteria for Substance use Problems (DSM IV)

Substance Use

• Substances that alter level of consciousness and/or perception

• Levels of use:– Experimental (occassional- not always safe!)– Recreational (regular, but within safe limits)– Bingeing/ dangerous use (high intensity over

short length of time)– dependence (increased tolerance and

withdrawals if stop)

Misuse of Drugs act 1971

• Class A- heroin, cocaine, ecstasy, LSD, anything prepared for IV use, cannabis oil

• Class B- amphetamines, oral opiates (DF118)• Class C- benzodiazepines, cannabis

Classification refers to perceived harm, and severe penalties for possession trafficking and supply. A carries highest penalties

Exercise 1

Ask yourself these questions:• What attitudes do I have about people who

use drugs and people who use alcohol? • Where did these attitudes come from?

(Parents, school, media, religious beliefs etc)

• How might these attitudes affect how I work with people with substance use problems?

Exercise 2: Why Use?

• Why do I (did I) smoke cigarettes; drink caffeinated drinks e.g. coffee, tea, cola; drink alcohol? Make a list of the reasons why, the benefits, and if there are any, some of the less good aspects of these habits.

• why do people with mental health problems use drugs and alcohol? Make a list of the reasons that you are aware of from what service users have told you, or assumptions that you have made.

Reasons for use

• To feel euphoric or feel nothing• To feel more confident• To work longer hours or enhance performance• To belong to a social group (peer pressure)• To kill time (alleviate boredom)• To alleviate physical pain and other health problems• Because it is a habit• To satisfy cravings and avoid withdrawal symptoms• For weight loss • To experience an altered state of consciousness• To unwind after a stressful day

Alcohol

• Alcohol is a widely used, legal and socially acceptable drug.

• It is taken orally. • It is a central nervous system

depressant • Dangerous drug; accidents

whilst intoxicated, overdose choking on vomit.

• Alcohol related to 40% of violent offences;44 per cent for domestic violence and 53 per cent for violence committed against a stranger [British Crime Survey, 2000].

Alcohol 2

• Safe levels <3 units per day • Males up to 21 units/week; females up to 14 units/week• Unit = volume x ABV/1000 (250mls wine

13%ABV/1000=3.25 units• Physical dependency- ↑tolerance and withdrawals• Signs of withdrawal: nausea, vomiting, sweating, high

temperature, hypertension, anxiety, sleeplessness, restlessness, and sometimes hallucinations, epileptic fits.

• Withdrawals need immediate medical attention and treatment as can be life-threatening.

• Never advise abrupt cessation of heavy drinking without treatment!!

Cannabis

• Cannabis is a sedative and hallucinogenic drug produced from the leaves and buds of the cannabis sativa plant.

• Most commonly used illegal drug. • Cannabis is an illegal substance under class B of the misuse of Drugs Act.

dried leaves or black/brown block of resin• Cannabis leaves or resin are smoked (roll-up with tobacco or in a bong)• Signs of Use: reddened eyes, dilated pupils, increased pulse rate,

drowsiness, giggling, and a sweet herbal smell. • Effects: relaxation, increased senses, slowing of thoughts, time seems to

pass more slowly, sometimes mild hallucinogenic effects.• Risks: mouth and lung cancer, exacerbate other lung conditions, increases

likelihood of psychosis, road traffic accidents whilst driving under the influence.

Cocaine and Crack Cocaine

• Stimulant drugs• Legality- class A drugs• What do they look like: cocaine is a white crystalline powder, and crack is white or

off-white crystalline rocks• How taken: Cocaine may be taken orally, snorted, inhaled, or injected. Crack:

inhaled from a pipe, but sometimes injected. • Effects: Cocaine, in both forms, increases heart rate, breathing, blood pressure,

thoughts and activity levels. It also lifts mood and gives a sense of energy and wellbeing.

• Signs of use: dilated pupils, dry mouth, elevated body temperature, teeth grinding, agitation, restlessness, excitability, pressure of speech, flight of ideas, weight loss (appetite suppressant).

• Risks: paranoia, confusion, and disorganized patterns of behaviour. The “come down” period causes fatigue, and depressed mood. Heart attacks, hgh blood pressure, stroke, and kidney damage

Opiates• Derived from the opium poppy. • They include heroin, morphine, methadone and codeine.• Central nervous system depressants • Legality: these are class A drugs • What they look like: heroin is a pale brown powder;

also available in pharmaceutically manufactured form such as tablets, green or blue syrup (methadone) and glass ampoules (for injection)

• How used: mainly smoked or injected, some opiates are available in tablet and suppository form.

• Signs of use: pallor, pinprick pupils “pinned”, sedation/drowsiness (“gouching out”), signs of injecting on body

• Effects: people feel emotionally numb, warm and drowsy, with an initial intense rush, especially if injected intravenously.

• Withdrawals: gooseflesh, shivering, profuse sweating, feeling feverish, aching limbs, yawning, runny eyes, runny nose, gastrointestinal disturbances such as stomach cramps, nausea, vomiting and diarrhoea.

• Risks: overdose, injecting related problems, BBVs, accidents

Other Drugs: solvents, ecstasy, LSD, amphetamines

Other Drugs• Hallucinogens: LSD, magic mushrooms

– Distort perceptions for several hours– “psychotic” trip– Can be terrifying “bad trip”

• Ecstasy– Stimulant and mildly hallucinogenic– Feelings of empathy, energy– Depression and short term memory problems– Death as a result of kidney failure

• Amphetamines– Effects like cocaine– Paranoia and aggression

• Solvents and gases– Sniffed, inhaled– Intoxication– Risk of instant death, brain damage, accidents

• Caffeine- – “Red Bull”; coffee; cola drinks– Stimulants, irritability, aggression, paranoia

• OTC- over the counter (cough linctus, anti-histamines etc)• Prescription drugs- benzodiazepines, anti-cholinergics