SUBSTANCE MISUSE IN MAINSTREAM CARE SERVICES
Where does someone who has a learning disability and an addiction go to receive help? What happens when an elderly person with a life crisis reacts by misusing alcohol, and needs help to stay in their home? Is there any recognition of their alcohol problem?
By DAVID FINNEY, provider relationship manager – Commission for Social Care Inspection
To address some of these issues, the Commission for Social Care recently arranged a series of seminars, briefly reported in the November 2007 Addiction Today. This brought together key stakeholders in the residential and domiciliary care field, including large corporate companies with services across the UK. Under consideration was the likelihood that there are people receiving mainstream care services whose addictions are not being treated.
By exploring two relatively overlooked areas – mental health and the elderly – it might be possible to highlight some of the reasons behind this and point towards possible solutions.
The issue of “dual diagnosis” in terms of mental health and substance misuse is a well-worn path. This does not mean to say that people in mainstream services receive help for their two problems in a completely ‘joined up’ way. At the CSCI seminar, Turning Point presented its recently published Dual Diagnosis Guide to Good Practice which highlighted areas where improvements can be made.
Learning Disability and addiction
Mike Delaney of Stepping Stones, a care home provider in Gloucestershire, explored this eloquently. He revealed two case examples which bring this area into sharp focus.
The first was an extremely vulnerable female with learning disabilities who was addicted to crack cocaine and working in the sex industry to fund her habit. She expressed a desire for help with her addiction but no one could be found to fund the specialist help she required. Mainstream residential care could not hope to meet the range of needs she was presenting.
A second example was of a vulnerable male with learning disabilities who was working as a rent boy, was HIV positive and hepatitis C positive. He was also misusing illegal drugs. No service provider would assume responsibility for his care.
Do we know how widespread this problem is? The most recent review of research has been undertaken by Adam Huxley et al at the University of Birmingham. This highlights the following:
- prevalence might be up to 2% of the general learning-disabled population using substances problematically
- misuse of alcohol among people with learning disabilities is about the same as non-cognitively impaired counterparts
- mild learning disabilities can be, in itself, a risk factor for adolescents who engage in binge drinking.
A rough estimate is that there could be 50,000-100,000 people with learning disabilities who are also problematic users of drug or alcohol. This means that, both in the 6,670 registered residential services and in the wider community, there could be a significant need which is not being met.
Delaney also pointed out that there might be secure units around the country in which adults with learning disabilities are held having committed schedule-one offences while under the influence of alcohol or drugs.
What are the barriers to this need not being met? The following facts spring to mind as possible causes.
- Assessment of people in the community with learning disabilities is unlikely to include the issue of substance misuse. So it is probably going unrecognised by mainstream service providers.
- It is likely that any negative consequences of problematic substance misuse will be deemed to be “challenging behaviour” for example, and dealt with on a behavioural level without addressing underlying causes.
- Staff in mainstream residential care services are not usually trained to screen for substance misuse.
- Registration of care services steers providers to register just the “primary need” which might lead to substance misuse being overlooked.
- Funding streams are either in the learning disabilities budget or under the auspices of Drug Action Teams who might not have a remit for the wider needs such as learning disabilities.
- Treatment for addiction in residential settings often requires a high level of cognitive ability to benefit fully from the programme on offer – a mismatch for someone with learning disabilities.
Delaney has developed the ‘Dorabella Model’ which, he believes, is well suited to meeting the complex needs presented by this client group. His description is that the model is “fully person centred and behavioural in nature. It addresses all areas of substance misuse, culminating in a bespoke service meeting the individual needs of service users”. Programme modules address motivation, self-awareness and behaviours linked with substance misuse. It goes on to address safe and risky thoughts, looking at the consequences of actions and problem solving. The approach offers the potential to meet the needs of this client group in a holistic way. It is hoped that commissioners will soon see that this represents a major step forward in service provision.
There is also a converse challenge for established residential rehabilitation centres to consider whether their programmes can be adapted for people with learning disabilities. The emphasis should be on concrete step-by-step problem solving and management of behavioural changes.
The next challenge would be to convince commissioners and purchasers of services that their service could provide a safe place for vulnerable people with learning disabilities. Under new registration guidance issued by the CSCI, there would not be the need to apply for additional conditions of registration. Instead, this could simply be built into the “statement of purpose” which each service already possesses.
Elderly People and substance misuse
This area could be even more overlooked than the preceding issue. Research is thin on the ground and much alcohol misuse amongst elderly people is probably under-reported.
The UK Inquiry into Mental Health and Well-Being in Later Life concluded simply that “more work is needed to gain a better understanding of alcohol misuse and mental health in later life”.
Alcohol Concern’s study found that, of people aged over 60 years old, about 23% of men and 8% of women endangered their health by drinking above the recommended guidelines. This means that over 2.5million older people are drinking at least five days a week. Furthermore, Alcohol Concern states that it is likely that this level is under-reported and that it might go undetected for longer than other age groups.
What is the significance of the problem for elderly people? With the changing demographics – a growing number of older people in the population – is this likely to be a growing problem? Alongside the increasing availability of alcohol, it seems to be an issue which will affect a rising number of older people in years to come.
How might problematic drinking first emerge among an older age group? What factors might lead to it being sustained?
Specific triggers can prompt an episode of alcohol misuse, or even the beginnings of an addiction to prescription drugs. These are highlighted by Alcohol Concern as:
- bereavement, especially of family or close friends
- loneliness and social isolation
- failing physical health
- loss of social function, income, skills.
All the above can lead to feelings of worthlessness and a lack of social and emotional support at times of vulnerability. So it is not difficult to see how someone could misuse alcohol, for example as a way of dealing with the emotional pain associated with such life changes in later years.
Alcohol misuse can also exacerbate health problems experienced by elderly people. So if a person is misusing alcohol, studies show that the following can be a consequence:
- earlier onset of dementia
- anxiety or depression
- increased likelihood of falls
- increased risk of hypertension or strokes
- self neglect, poor nutrition, hypothermia.
If these problems are noticed when elderly people are living in their own homes, it is likely that that they will be considered to be problems linked with ageing rather than indications of problems with alcohol. This raises a challenge for domiciliary services to appropriately assess the wide range of needs and their potential causes.
Mick Davies, who is development manager of addictions services for the Huntercombe group, addressed this at the CSCI seminar. He focused on the incidence of alcohol misuse in residential care for elderly people.
First, he issued the challenge to homes to develop an alcohol policy for residents in their ‘statement of purpose’. He questioned how often someone’s alcohol consumption is assessed. For some, it could be an unproblematic aspect of their life; they would like the option of continuing their moderate consumption of alcohol. However, if it is not asked on admission, residents might be denied this aspect of their lives that was a feature for many years.
Second, he challenged the sector to consider the use of validated screening tools which would allow accurate assessment and planning of care. He argued that more specialised assessment could be undertaken if there was a point when concern was raised about use of alcohol.
Third, he challenged homes to consider the training of staff to include drug and alcohol awareness in their core training programmes. If this does not happen, he warned that substance misuse might continue to go unrecognised or incorrectly treated.
Fourth, Davies challenged homes to make contact with specialist community addictions services, so that appropriate help could be accessed when required.
Finally, he concluded that a key feature in a care planned approach was working with the agreement of the elderly person concerned. Without this, services would be showing a lack of respect and diminish the chances of successful treatment.
The wider challenge is for community-based services around the country to accept that substance misuse might be a problem for some elderly people, and to consider it in the assessment of their needs as well as in the planning of their care services.
- Substance misuse among the learning disabled and elderly population is probably a “hidden phenomenon”.
- Issues of substance misuse can be “masked” by other problems associated with each client group.
- Specialist services for the treatment of addictions among these population groups are probably underdeveloped.
- More research is needed to establish both incidence and effects of substance misuse.
- Commissioners and service providers need to be challenged to meet the complex needs of the elderly and learning disabled client groups.
A Huxley et al (2005): Substance misuse and the need for integrated services in Learning & Disability Practice vol 8 no 6 July 2005.
Alcohol Concern (2002): I don’t mind if I do.
Turning Point (2007): Dual Diagnosis: A guide to good practice.