Support Individuals who are Substance Users

The optional unit ‘Support Individuals who are Substance Users’ requires learners to have an understanding of a range of substances, encourage safe handling of substances, support individuals when they are using substances and support individuals to reduce their substance use.

Learning Outcome 1:- Understand about different substances, their effects and how they might be used

1.1 Identify the different substances which individuals might use, how they are used and their likely effects

At my service, we work with service users who use, sometimes in combination, substances such as the following:

Alcohol – almost always consumed orally however I have known of it being injected or vaped. Effects: distorted perception, chaotic and unpredictable behaviour, disinhibited, at high risk of physical harm, reduced motor neuron skills, feel less anxious and more sociable Slurred speech, nausea, psychological and physical dependence.

Opioids – which comes in a variety of different forms and therefore consumption can occur via a variety of different ways. Most commonly opiates are injected intravenously, Smoked using foil or in a joint, orally via liquid form or pill form. – Effects: lower heart rate, shallow breathing, stoned feeling, gouging, low blood sugar level, extreme relaxation. Intense pleasure, warmth, detachment Nausea, drowsiness, overdose, psychological and physical dependence.

Tranquillisers / sedatives – Benzodiazepines, Valium, Diazepam taken as tablets, capsules, injections or suppositories. Effects: calmness, relaxation, drowsiness, anxiety, insomnia, decreased concentration, tremors, nausea, vomiting, headaches, anxiety, panic attacks and depression, psychological and physical dependence.

Stimulants/party drugs – this includes ecstasy/MDMA, Amphetamines, cocaine/crack and new designer drugs. These are most commonly consumed orally via pill form or nasally in powdered form. Effects: High state of consciousness, increased heart rate, sweating, increased thirst, Exhilaration, alertness, excitement, high energy, tremor, depression, heightened perception of colour and sound Lack of sleep, dehydration, Euphoria, increased energy Anxiety, panic, paranoia, etc.

Psychoactive – cannabis is usually smoked in a roll-up or pipe. It is also frequently ingested orally. Effects: stoned, increased heart rate, reduced blood sugar level, decreased sensory awareness, increased sensory awareness, relaxation, disinhibition, increased sensory awareness Red eyes, anxiety, confusion, psychosis, etc.

Using substances can lead to substance-related disorders of intoxication, dependence, abuse, and withdrawal caused by various substances including: alcohol, inhalants, prescription medications that are supratherapeutically abused (such as sedatives or opioids), as well as illicitly attained drugs like amphetamines, opioids (opium, heroin), cannabis, cocaine (inc crack-cocaine), hallucinogens, and phencyclidine (PCP).

According to the ‘Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revised’ (DSMIV-TR), all of the substances listed above have disorders of two types: substance use disorders and substance-induced disorders.

Substance use disorders include abuse and dependence.

Substance-induced disorders include intoxication, withdrawal, and various mental states (dementia, psychosis, anxiety, mood disorder, etc.) that the substance induces when it is used.

The DSM-IV-TR lists disorders in the following categories: > alcohol-related disorders > amphetamine-related disorders > cannabis-related disorders > cocaine-related disorders > hallucinogen-related disorders > inhalant-related disorders > opioid-related disorders > phencyclidine-related disorders > sedative-, hypnotic-, or anxiolytic-related disorders > polysubstance dependence.

Intoxication is the direct effect of the substance after a service user has used or has been exposed to the substance. Different substances affect individuals in various ways, but some of the effects seen in intoxication might include impaired judgment, emotional instability, increase or decrease in appetite, or changed sleep patterns. Substance abuse is continued use of a substance in spite of social related or interpersonal problems, but the user has not gotten dependent on the substance. The individual who abuses a substance may experience legal problems and may have problems fulfilling responsibilities, such employment or parenting.

Substance dependence is characterised by continued use of a substance even after the user has experienced serious substance-related problems. The dependent user desires the substance (“craving”) and needs more of the substance to achieve the effect that a lesser amount of the substance induced in the past. This is known as tolerance. The dependent user also experiences withdrawal symptoms when the substance is not used. Withdrawal symptoms vary with the substance, but some symptoms may include increased heart rate, shaking, insomnia, fatigue, and irritability.

1.2 Identify the risks involved with substance use both in the short and the long term (e.g. overdose, dependence and associated health risks)

Substance use can have a wide range of other short- and long-term, direct and indirect effects and risks. These often depend on the specific drug or drugs used, how they are taken, how much is taken, the person’s health, and other factors. Compulsive cravings combined with prolonged abuse can lead to long-term negative health risks.

Most substances will cause strain on the organs, as well as the venous and respiratory system after prolonged use. Many forms of substance misuse can alter the user’s physical make-up, sometimes even just after a few weeks of use. Short-term risks can range from changes in appetite, wakefulness, heart rate, blood pressure, and/or mood to heart attack, stroke, psychosis, and overdose. These may occur after just one use. Longer-term risks can include heart or lung disease, gastrointestinal disease, hormone imbalance, cancer, mental illness, HIV/AIDS, hepatitis, prenatal and fertility issues, and others.

In addition to the above medical concerns, chronic use of certain substances can lead to long-term neurological impairment, such as exacerbating or giving rise to mental health problems. Neurological and emotional risks of substance abuse include the following mental health conditions:

• Depression
• Anxiety
• Memory loss
• Aggression
• Mood swings
• Paranoia
• Psychosis

The ultimate health consequence of substance abuse, of course, is death – either caused directly by a situation such as an overdose, heart attack or misadventure (whist under the influence: falling over, crashing a car etc.), or eventually through the development of drug-induced cancer, AIDs, etc.

Many addictive substances are highly regulated and, in certain situations, illegal. Being caught with a large quantity of drugs or committing acquisitive offences to support a habit could result in a prison sentence. If found guilty on criminal charges, the individual could have trouble finding employment, especially after serving a prison sentence. Some of the most common legal consequences of substance misuse are:

• Large fines
• Extensive jail sentences
• Probation
• Arrest records that make it difficult to find a job
• Driver’s license suspension and transportation difficulty
• Strict community service requirements
• Restrictions on living in certain communities

Substance misuse and certainly dependence can lead to major risks in user’s financial situation. Consistent drug or alcohol abuse is generally a costly lifestyle to maintain. The individual may accrue debt, and may suffer setbacks along the way such as divorce, home foreclosure and vehicle repossession. If the user ends up losing a job or getting arrested as a product of the addiction, the financial cost piles up even further.

Addiction is hard to hide, and as chronic substance abuse continues, social risks can mount in almost every aspect of the user’s life. Their ability to concentrate may be diminished, their mood may fluctuate, and their interests will likely change as drug cravings become compulsive. Risks here can include:

• Loss of employment
• Relationship changes between both friends and family members
• Aggression toward friends and family members
• Divorce
• Suspension or expulsion from organized activities, such as sports teams

Addiction almost always harms the user’s personal and professional life. Mood swings can become unpredictable and hard to control, and other health issues such as chronic fatigue can make it hard to function in many facets of society. The social risks of drug addiction usually include tension within a family, if not outright conflict, even if the user hides their substance intake well.

Friendship dynamics often change as well, as non-users will increasingly find less in common with (and struggle to enjoy the company of) friends who continuously use. Often as a consequence an individual may only find comfort when around other people who abuse substance. In other cases, the individual’s social circle may shrink to the point where they continue to abuse substances on an individual basis, with very little human contact in between. Loneliness and social isolation can become a major risk, and mental health conditions like depression or social anxiety can develop. The worst-case scenario in this situation is the lonely individual is at risk for suicide, and may try to overdose on purpose.

Substance use can negatively impact everyone in the family, but too often children and adolescents are most affected by the addiction of a parent.

• Children may experience neglect and abuse. Many child abuse cases are within families where substance misuse are also present. As well, parents with a substance abuse problem will often put their substance use first, leaving their children to fend for themselves, leading to cases of neglect of varied severity.
• Parental inconsistency. Even if severe neglect and abuse are not present, alcohol and drug addiction can lead to inconsistent parenting, including erratic rules and inconsistent consequences. In these situations, children may experience confusion about what is right and wrong, as they receive mixed signals from parents about acceptable behaviour.
• Children take on adult roles. When parents suffer from addiction, their children often end up taking on parental roles. Especially older children in the family may take on responsibility well past what is expected of other children their age by looking after siblings, cooking, cleaning, and even providing emotional support to the substance misusing parent.
• Emotional instability and behaviour problems. Growing up with parents who abuse drugs and alcohol creates an environment of chaos and instability. Children from homes where one or both parents are struggling with substance misuse can experience shame, guilt, confusion, fear, and insecurity as their emotional development is not nurtured or made a priority within the family.

Alcohol and drug abuse affects intimate relationships in specific ways, often with one or both partners exhibiting signs of codependency. 

Codependency refers to a pattern in relationships where one person puts the needs of the other in front of their own. When addiction is present, the substance misusing partner may fall into the role of caretaker and display symptoms of codependency. When this relationship pattern is present both individuals suffer and both often need treatment in order to break the cycle.

The following are a few symptoms of codependency and ways in which substance misuse affects those closest to the user.

• Low self-esteem stemming from feelings of shame, guilt and inadequacy. Often spouses will try hard to be perfect and please their partner, under the false belief that if only they were good enough their partner would stop using.
• Controlling behaviour. Codependents may believe others cannot take care of themselves which leads them to exhibit controlling behaviour in all situations.
• Become dependent on the approval of others. Codependent partners may forfeit their own values in order to avoid rejection and anger and please others. Their self-worth may be based solely on the approval of others which leads to excessive people pleasing.
• Obsessively think about other people to the point of neglecting one’s own needs. They may believe they are being selfless in their desire to care for the needs of the addict, but this behaviour is enabling and detrimental to both people in the codependent relationship.

Substance use poses risks for pregnant women and their babies. Drugs may contain impurities that can be harmful to an unborn baby. Pregnant women who use drugs may be more likely to harm the foetus with risky behaviours and poor nutrition. Drug use can lead to premature birth or low birth weight. It can also cause the baby to have withdrawal symptoms (sometimes in the form of neonatal abstinence syndrome), birth defects or learning and behavioural problems later in life.

In my service – our risk assessments are referred to as ‘risk reviews’ and are dated & recorded on the online client file and have an automatic three month review date once they are completed so that their accuracy and currency can be checked at regular intervals, however they rarely get to that and in most of my cases are reviewed fortnightly, and often weekly. The risk review contains information about the service user and the type of support they need. My clients can face risks in many different areas including:

• Substance use
• Physical health
• Mental health
• Risk of harm to children
• Risk of harm to adults
• Risk of harm from others
• Risk of harm to self.
• Social stability.

1.3 Explain legislation, policies and guidelines on the use and storage of substances

Regarding how I ensure the safe and legal storage and disposal of suspected illicit substances – (which are irregularly handed in by service users either of their own violation or as agreed in their service user plan as part of their ceasing to use / reduction in use), including the receiving of an illicit substance, storage requirements, documentation, and destruction / disposal.

n respect to medication that we store and either administers (Hepatitis B vaccines) or provides (naloxone) to service users; I follow our guidelines and policies whilst supporting my colleagues responsible (Service manager, team leaders, nurses, naloxone champion etc.) which include:

• Medication storage failure procedure
• Stock management form
• Expiry date check form
• Controlled drugs procedure
• Storage of emergency drugs procedure
• Waste management policy
• Vaccinations: ordering, storage and handling procedure
• Fridge temperature monitoring form
• Room temperature monitoring form
• Prescription security management policy
• Medicines management in community

As the last is the most pertinent (to ensure appropriate handling, supply and administration of medicines in our community services, in order to provide safe and effective medication to service users in line with legislation, product licences and good practice guidance).

Regarding medication that we have prescribed (acamprosate, naltrexone, nalmefene, metoclopramide hydrochloride, prochlorperazine, buprenorphine & methadone etc.) or provided (naloxone) to service users I follow our guidelines on supporting them with safe storage and disposal of their medications.

The Misuse of Drugs Act 1971, whose main purpose is to prevent the misuse of controlled drugs – achieves this by imposing a complete ban on the possession, supply, manufacture, import and export of controlled drugs except as allowed by regulations or by licence The Misuse of Drugs Regulations 2001 (MDR) uses the power set out in the Misuse of Drugs Act 1971, section 7, to provide exemptions from the Act, making it lawful for certain people to produce, supply and possess certain controlled drugs.

MDR also contains requirements relating to record keeping and documentation for controlled drugs.

The term ‘controlled drug’ is defined by the Misuse of Drugs Act 1971 as ‘any substance or product for the time being specified in Part I, II or III of Schedule 2 of the Misuse of Drugs Act 1971’. Controlled drugs are subject to strict legal controls and legislation determines how they are prescribed, supplied, stored and destroyed. Controlled drugs are managed and used in a variety of settings by health and social care practitioners and by people who are prescribed them to manage their condition(s). Controlled drugs are closely regulated as they are susceptible to being misused or diverted and can cause harm. To ensure they are managed and used safely, legal frameworks for governing their use have been established.

Over the years there have been a number changes to legislation for managing controlled drugs as a result of controlled drugs related incidents including service user safety incidents. The Shipman Inquiry’s Fourth Report made a number of recommendations to strengthen the governance of controlled drugs and for monitoring their movement from prescriber to dispenser to service user. In December 2004 the Government’s response to the Shipman Inquiry, Safer Management of Controlled Drugs was published. The response accepted that systems should be strengthened provided that they did not prevent access to controlled drugs to meet service users’ needs.

NICE guidelines make evidencebased recommendations on a wide range of topics, from preventing and managing specific conditions, improving health, and managing medicines in different settings, to providing social care and support to adults and children, and planning broader services and interventions to improve the health of communities. They aim to promote individualised care and integrated care (for example, by covering transitions between children’s and adult services and between health and social care). NICE guidelines cover health and social care in England and use the best available evidence; they involve people affected by the guideline and advance equality of opportunity for people who share characteristics protected under the Equality Act (2010).

In addition to the recommendations, guidelines also summarise the evidence behind the recommendations and explain how they were derived from the evidence. Many guideline recommendations are for individual health and social care practitioners, who should use them in their work in conjunction with judgement and discussion with service users. My colleagues and I take NICE guidance fully into account when exercising clinical judgement, but it does not override our responsibility to make decisions appropriate to the circumstances and wishes of the service user.

Learning Outcome 2:- Be able to enable individuals to adopt safe practices associated with substance use

2.1 Explain factors that influence individuals to use substances and reasons why individuals decide to reduce or cease substance use

There are many reasons why individuals may be influenced to use substances – including:

• To help them cope with difficult feelings or circumstances
• To ‘self-medicate’ mental health problems
• Socialising in a context where it is ‘normal’, or as a result of peer pressure or to ‘fit in’
• To have a new experience (especially during adolescence when people often take more risks)
• Because they enjoy the feeling of increased confidence, energy or relaxation that drugs can bring.

There are a number of risk factors for developing substance misuse problems. These include:

• Family members with an alcohol or other drug problem – possibly because they have similar genetic vulnerabilities or because of the experience of living with them in shaping thinking and attitudes
• Family members’ or own mental health problems
• Lack of parental supervision and engagement in formative years
• Lack of connection with peers or community
• Poor coping skills and emotion regulation skills
• Early neglect, abuse or trauma – which can affect brain development and affect thinking & emotional control

Any of the risks involved with substance use identified in 1.2 above may be sufficient for individuals to decide to reduce or cease substance use or all of them might not be enough. The most common reasons I hear for individuals wanting to stop or cut down included:

• Being worried about or advised to regarding their physical health or mental health
• Changes in their lives (like starting a new relationship or having a child) which they see as not fitting in with their substance using lifestyle
• Reflection on financial cost
• Worries about addiction, bad experiences with drugs or after effects. Development of withdrawal symptoms
• Negative impact on relationships with family
• Losing contact with suppliers or dealers
• Preferring to feel in control and moving on from what some described as boring &/or self-destructive behaviour

As considered in 1.1 above – If an individual develops a substance-related disorder of abuse or dependence it can be virtually impossible to ‘just stop’ using substances. Dependence especially creates and results from changes in brain chemistry which can make an individual’s requirement for a/the substance overpower all other considerations.

In order to provide support for the individual, it helps to understand their behaviour and the motivations behind it. A popular model for explaining the stages a user goes through is the Cycle of Change. An service user typically (though not always) goes through the cycle several times as part of their recovery journey; the model helps explain that lapse and relapse are a common part of the journey for individuals trying to give up any substance:

1. Pre-Contemplation – In this stage the substance user has no desire to change. They do not see their using as problematic, even if others do.
2. Contemplation – At this stage the substance user starts considering their situation and whether they want to change. They are more aware of their situation and may want to get out of it. However, they are still using at this stage.
3. Preparation – Here the user makes a decision to change their substance using behaviour and starts to prepare themselves to do so.
4. Action – At this point the user takes practical steps to bring about a change to their substance using behaviour, such as using less or deciding to give up completely.
5. Maintenance – When someone reaches maintenance they have achieved a change in their substance using behaviour. A substance user may have either stopped using drugs or alcohol, or moved to a more controlled, less harmful way of using and is maintaining that change.
6. Lapse and Relapse – A lapse is when the user briefly returns to their old substance using behaviour. It is possible for them to go from lapse back to any stage of the cycle. However, a relapse is when the user fully returns to their old substance using behaviour and then needs to go all the way through the Cycle of Change again.

My personal and professional experience is that those in long term recovery (myself included) are usually abstinent and tend to live in ‘5. Maintenance’.

2.2 Communicate with individuals in a manner that maximises the individuals’ understanding

In my work setting I use communication to form, develop, promote and maintain relationships, and strategies that can be used to maximise the possibility of information being heard and understood. I need to be effective in my communication to build two-way trust, develop understanding & awareness and ultimately provide effective care & support to service users and colleagues whilst making clear my own goals / needs.

When working with service users it is critical to be able to support them to achieve their goals – by giving them autonomy over their decisions, listen to their problems, reflect on their thoughts and feelings, and offer support, reassurance and guidance.

Communicating with individual service users on a regular and thoughtful basis will enable them to build trust and confidence in our relationship and will enable me to know the type of support they require. Without communication a therapeutic relationship would not exist. There have been many service users I have worked with who have become very distrusting of services or society in general due to their mental health issues &/or past experiences – and this requires more time and often more intensive work – in order to build trust, gain a true understanding of what they have been through, what they feel, how they can be supported, and to effectively communicate.

I find effective communication involves arriving at a shared understanding of a situation and in some instances a shared course of action. This requires a wide range of generic communication skills, from negotiation and listening, to goal setting and assertiveness, and being able to apply these skills in a variety of contexts and situations.

Effective communication also requires myself and my team having access to adequate and timely information necessary to perform our role effectively and appropriately. The use of technical terms and jargon, acronyms and abbreviations and diagrams to communicate can influence how well information is shared and therefore the effectiveness of communication. As in other sectors; adhering to the five standards of effective communication is likely to facilitate improvements in the exchange of information between professionals, and information should be:

1. Complete – It answers all questions asked to a level that is satisfactory to those involved in the exchange of information.
2. Concise – Wordy expressions are shortened or omitted. It includes only relevant statements and avoids unnecessary repetition.
3. Concrete – The words used mean what they say; they are specific and considered. Accurate facts and figures are given.
4. Clear – Short, familiar, conversational words are used to construct effective and understandable messages.
5. Accurate – The level of language is apt for the occasion; ambiguous jargon is avoided, as are discriminatory or patronising expressions.

In promoting effective communication I consider both verbal and non-verbal communication. In verbal communication, my language must not be a barrier. Also, the tone and pitch of my voice must be calm. The use of non-verbal expression like eye contact, facial expression, gestures, touch, body movement & posture when use in communication make the message being sent be understood.

The actions I display while communicating will tell whether I am interested in the conversation or not. Other factors can also include active listening, direct expression as well as cooperative dialogue. I must be aware of what I hear, clear in what I say and open to responses of views and opinions of others. I do my best to notice when an individual is becoming confused, angry, upset, stressed or anxious without them telling me. I can then take action to help stop this from happening or help them express their feelings in the best way for them. Recognising the unspoken messages can help me to ask good questions and develop supportive relationships. It improves trust as the individual can see that I am interested in them and trying to understand and meet their needs.

People from different cultures, religions and different backgrounds communicate and interpret things in different ways. In some cultures, people communicate with bold gestures or use touch as norm, however to other people from another background this could be deemed as offensive or inappropriate, for example having direct eye contact when talking to someone who is English would be considered fine whereas would be considered very rude if one were Greek.

It is key to be able to communicate in way that is appropriate to the service user so they will understand, the language used should be consistent with the their own form of expression (for example, not clinical), and I am mindful that sayings and abbreviations that may be used by a Service User who is from southwest London (i.e. always lived locally to where the service is based) may differ from someone who has moved recently from Scotland.

Using communication which is relevant to that person will help to build up trust and regard; as it demonstrates respect and a level of conscientiousness on my part. It is important for me to develop and maintain an understanding around beliefs and values associated with different cultures or groups, for example religious belief or gender specific beliefs, and taking into consideration appropriate greetings or gestures to avoid. I would also check the service user’s records from the information collected prior or during the assessment to pre-empt what requirements might be needed – not knowing this information could have detrimental effects to the therapeutic relationship as we could appear uncaring to the individual’s needs, rude or disrespectful.

If a service user is highly intoxicated or in withdrawal it effects their ability to listen or communicate rationally therefore making communication poor or ineffective. If a service user was not of a good emotional or physical state, for example if someone was in a lot of pain or feeling anxious, upset or angry they may not be able to communicate or listen as effectively.

Some service users are required to attend due to a court order, by social services, or their housing provider – so their readiness for change and to address their substance misuse are far from optimal. This creates resistance in wanting to be supported, so these service users are more prone to be defensive and guarded which affects their willingness and readiness to communication with me.

Environmental factors can affect the way an individual feels and so communicates, such as privacy, lighting, external noise, positioning of the furniture, the presence of others, the space available and the way I am positioning myself to keep an open yet safe space.

In service user one-to-ones I ensure I have allotted enough time to allow the service user to discuss matters and allow myself to offer back relevant support, as well as go through the issues I wish to bring to the session; however if my schedule is running behind this can be particularly challenging – and I need to ensure I am in the right frame of mind to communicate with service users as if I am feeling stressed this could affect the way I would listen and communicate.

There have been many service users I have worked with who have become very distrusting of services or society in general due to their mental health issues &/or past experiences – and this requires more time and often more intensive work – in order to build trust, gain a true understanding of what they have been through, what they feel, how they can be supported, and to effectively communicate.

As stated in above, language barriers including dialect, inappropriate words etc. would be a barrier to effective communication, hence the importance (if required) of finding out if an interpreter is available prior to an appointment so we can communicate with each other. I work with a lot of service users who have mental health issues, sensory / physical impairments &/or learning disabilities which can be a barrier in communication if I’m not aware or appropriately prepared for.

2.3 Support individuals to discuss their circumstances and history of substance use

The service users are at the centre of support I and my colleagues provide, so I must not only understand their goals from treatment, but also find out as much as I can about their circumstances and history of substance use and record it so:

• A bespoke package / plan can be created with & for them (rather than an ‘off the shelf’ plan prescribed to them).
• I (and colleagues) know what to watch out for regarding the indicators of triggers, lapse, relapse, increase / change in use, etc.
• They trust me and are more likely to work with me, take suggested actions, come to me with concerns.

We carry out extensive triage and assessment when individuals are referred / re-referred to us but as they may often be initially hesitant to fully disclose their full circumstances and history of substance use (due to fear of judgement, trust issues, anxiety around what agencies might get involved / be notified – i.e. probation, social services etc.) and I spend the first few one-to-one sessions building trust and establishing their frame of reference.

As I build the relationship with the service user; speaking to them about their history, I am able to understand more about the experiences that have informed the person they are (for example, I may do this by asking about their childhood and family background), which not only allows me to better understand them; but will also allow them to feel respected and valued and not just another service user.

The individual’s substance use circumstances and history may impact on their beliefs, values and culture. I find out about an individual’s beliefs by asking them what they view as important. I find out about an individual’s needs by asking them what treatment and support needs they have and what they require to meet these.

To support service users to effectively identify a truthful picture of their circumstances and history of substance use which can form the foundation of their recovery – ‘Acceptance’; I record relevant discussions on their service user plan (SUP), the aforementioned integrated risk and recovery plan which provides a central place to record the ongoing assessment, review and management of goals, risks and actions. There are eight domains in a SUP, one of which is specifically for substance use.

All reviews are dated & recorded on our system and once saved cannot be amended. When opening a new review throughout the treatment journey it pulls through the ‘risk indicators’, ‘protective factors’, ‘completed actions’ and ‘outstanding actions’ for each domain so what has been discussed previously can be reflected on. Another discussion support method I use in keyworking sessions is the Treatment Outcome Profile (TOP) which provides a useful baseline to measure (amongst other things required by the National Drug Treatment Monitoring System – NDTMS) their specific substance use. It is useful to see patterns and changes in current using. Our system has the facility for using the information to generate a graph / map providing a visual record of changes, which can be easier to understand and have more impact on the service user than a list of numbers.

2.4 Advise individuals on ways in which methods of substance use and activities affected by it can be practised more safely

The primary method I use in keyworking sessions to advise service users on ways in which methods of substance use and activities affected by it can be practised more safely; is in the regular and effective use of their service user plan (SUP), an integrated risk and recovery plan which provides a central place to record the ongoing assessment, review and management of goals, risks and actions. The SUP is updated in each keyworking session in the form of ‘risk reviews’ recorded on our system usually fortnightly, and often weekly. The risk review contains information about the service user, their substance use and activities affected by it. They can face risks in many different areas and our system separates it out into the following domains:

• Substance use
• Physical health
• Mental health
• Risk of harm to children
• Risk of harm to adults
• Risk of harm from others
• Risk of harm to self
• Social stability

In each of these domains we will collaboratively consider how to practice more safely the methods of substance use &/or activities affected by it to minimise the risk / harm (i.e. risk of injecting heroin on physical health, or risk of using alcohol when the children are staying overnight). When opening a new review throughout the treatment journey it pulls through the ‘risk indicators’, ‘protective factors’, ‘completed actions’ and ‘outstanding actions’ for each domain so the effectiveness of the action to practice more safely the methods of substance use &/or activities affected by it (i.e. smoking heroin rather than injecting it, or only use alcohol when the children are staying overnight with their other parent) is carefully re-examined and the progress reviewed. If review of the risk and addressing action concludes that changes to the plan are required, then those changes must be made. See 2.6 below for advice that I have previously given to / or actions agreed in a SUP with service users.

2.5 Support individuals to dispose of hazardous materials and equipment safely

Regarding how I ensure the safe and legal storage and disposal of suspected illicit substances in the service – (which are irregularly handed in by service users either of their own volition or as agreed in their service user plan as part of their ceasing to use / reduction in use), including the receiving of an illicit substance, storage requirements, documentation, and destruction / disposal; I follow the our policy. When service users are disposing of medication that we have prescribed (acamprosate, naltrexone, nalmefene, metoclopramide hydrochloride, prochlorperazine, buprenorphine & methadone etc.) or provided (naloxone) I follow our guidelines on advising them to:

• Unwanted medicines are an increased hazard to young children and should always be stored out of reach, and disposed of as soon as they are no longer required
• Do not store left over controlled drugs at home
• Return leftover medications to the local pharmacy. It is a free service and is available at every pharmacy
• Never dispose of medicines down the toilet or sink. Medicines disposed of in this way can become a hazard to the environment and water supply.

We have a Needle & Syringe exchange Programme to ensure that service users are provided with take home sharps bins and advice on how to dispose of needles, syringes and associated paraphernalia safely, in addition to providing a means for safe disposal of used / full bins and equipment – all service users are encouraged to return used injecting equipment on every visit in the sharp bin containers provided. All returned equipment whether used or unused must be treated as clinical waste presenting an infection risk and disposed of as such.

2.6 Describe harm reduction strategies, how and why these may differ from individual to individual

‘Harm Reduction’ refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption.

Harm reduction benefits people who use drugs, their families and the community. When service users are storing medication that we have prescribed (acamprosate, naltrexone, nalmefene, metoclopramide hydrochloride, prochlorperazine, buprenorphine & methadone etc.) or provides (naloxone) I follow our guidelines on advising them to:

• Never leave medications unattended even for a few minutes.
• Make sure take the right dose.
• Keep medicines in their original packaging.
• Use the measuring cup provided by the pharmacist.
• Avoid taking medication in front of children.
• If they spill liquid medication (e.g. methadone), clear it up immediately. Wash any cloths used or dispose of any paper towels properly.
• Never share medication with other people as this could be dangerous.

I advise service users that from paracetamol to prescribed methadone it’s important to make sure that the medicines they keep are stored correctly, are in date and are safe to take, and always discuss with them how their methadone (we usually prescribe it in liquid form, which is bright green) and/or other medicines can look very inviting to a child and/or a vulnerable adult. It must be stored safely – a locked cupboard that cannot be reached is the most suitable place. If they have problem storing their medications, I provide them with a safe storage box. If they have children in their home I inform them about children not having tolerance to methadone, so even small amounts can kill them because they may stop breathing, vomit, or choke on their own saliva because they cannot swallow whilst unconscious, and if they think a child has swallowed any amount of methadone, however small, they must ring 999 immediately. To never store medication in low cupboards, in shopping bags, under the bed, on window sills, in the bathroom, in a car glove-box, or in the fridge (unless advised to do so).

Opioid using service users have to actively opt out of receiving a naloxone pen and the accompanying training. The number of deaths in which heroin or morphine are involved has increased dramatically in recent years. Naloxone is quickly and easily administered, and can prevent such deaths by temporarily reversing the effects of opioids. We have a Needle & Syringe exchange Programme, which aims to reduce the transmission of blood-borne viruses and other infection caused by sharing injecting equipment, such as HIV, Hepatitis B and C. In turn, this will help to reduce the prevalence of blood-borne viruses and bacterial infections, so benefiting wider society. It also aims to reduce the other harms caused by drug use by:

• Providing advice on minimising the harms caused by drugs.
• Helping to stop misuse by providing access to drug treatment (e.g. opioid substitution therapy)
• Access to other health and welfare services
• Ensures people who inject have access to safe disposal facilities.

The below is not an exhaustive harm reduction advice list, but it gives a good general overview of the advice that I have previously given to / or agreed in a SUP with service users. It is important I deliver information that is directly relevant to the drugs and methods that individual is using. People have a tendency to remember positives and forget negatives when looking back on events, and this could skew the information that they hear from me when they think back at a later date. However if what I am saying is directly relevant to their behaviour they are more likely to listen and take on board what I am saying.

Some of this information is more relevant to recreational users and other is more useful for regular / dependent users.

• General Harm Reduction Measures:
  • Don’t mix drugs – this includes alcohol and prescription drugs.
  • Don’t take drugs during pregnancy.
  • Don’t take drugs and drive or carry out any other potentially dangerous activity.
  • Remember that drugs may impair judgement in sexual matters and can increase risk of HIV infection, STI’s (like thrush, herpes, syphilis, gonorrhoea, chlamydia and hepatitis).
  • Seek help if you find you are having to increase the dose of a drug to get the same effect. This indicates that tolerance and possibly dependence is building up.
  • Don’t take drugs, if you have certain medical conditions, for example stimulants and heart conditions do not go well together.
  • Don’t take drugs alone – being with friends can keep you safe and help when you come down.
  • Tell your friends what you are taking so if one of you runs into trouble of any sort, the others will know what to do.
  • If possible, use a safer alternative to injecting drugs.
  • Remember that in most cases you only think you know what you are buying and taking even if it’s from a friend you have previously bought from.
  • The effects of drugs can vary according to height, weight and emotional state generally people of lower weight have more effects from drugs.
  • Drugs can often be expensive – try not to borrow off friends or buy on credit from dealers, and set a limit on what you are going to spend.
  • Try not to put off coming down. The longer you put it off, the worse it will be. In particular, if you’re using stimulants, avoid using heroin or a benzodiazepine like Valium or temazepam to take the edge off the stimulant come down. These are physically addictive and could result in dependency.
  • Start off slowly – don’t take too much of any drug in one go.
  • Always try and stay aware of the temperature in your surroundings.
  • Try to find out as much information about the drug you are going to try before using it.
  • Don’t use on an empty stomach. Always make sure you eat well before you take drugs.
  • Try and eat the day after taking drugs even if you don’t feel like it.
  • Keep hydrated whilst using and the day after. Drink roughly 2litres per day.
  • Get some sleep after taking drugs. Staying up all night is harmful in itself.
• Alcohol:
  • Don’t drink on an empty stomach. Remember to eat whilst drinking.
  • If you are drinking every day, consult a medical professional before suddenly stopping drinking. It can be dangerous to stop suddenly.
  • Don’t drink and drive – you could hurt yourself or worse, somebody else.
  • Don’t drink too much if you know it has a bad effect on your behaviour, for example making you aggressive or depressed
  • Drink a pint of water before going to bed to rehydrate your body and to help reduce the hangover the next day.
  • If you are drunk, coffee may wake you up but it will not sober you up.
  • You can become addicted to alcohol.
  • Don’t drink strong drinks at the same speed as weaker drinks – i.e., don’t drink wine as fast as beer.
  • Be careful how much you drink if pregnant.
  • Don’t drink if on certain medication (always read the label).
  • Don’t mix with other drugs (especially depressants such as heroin or tranquillisers).
  • Stay with friends to ensure you don’t go off with someone you don’t know.
• Ecstasy / MDMA:
  • Don’t mix with alcohol or other drugs.
  • Take pills in halves or quarters. It’s safer and you can always take more later.
  • Test a small amount of powder before taking a large amount.
  • Wearing hot clothes, hats and gloves dehydrates and overheats you.
  • If at a hot party, take time out to cool off – a 10 minute break from dancing every hour lets your body rest.
  • Drink water or fruit juice to replace lost fluids. Drink 1 pint over an hour – only do this if you are dancing, sweating or hot, drinking too much water can be dangerous as your body can’t process it so well on MDMA/Ecstasy.
  • Eat well before taking ecstasy and the day after, even if you don’t feel like it.
  • Ecstasy testing: it will let you know what is in your pill, but this doesn’t make it safe. People can still react badly to pure MDMA.
• Amphetamines/speed:
  • Don’t take speed if you have any heart problems.
  • Don’t mix with other drugs or alcohol. Speed stops you feeling like you are drunk although the physical effects are still there.
  • Drink water or fruit juice to replace lost fluids. Drink 1 pint over ‘an hour – only do this if you are dancing, sweating or hot.
  • Test speed in small doses to check how strong it is.
  • Eat well before taking speed and the day after, even if you don’t feel like it.
  • If you have ‘base’ be very careful, a small amount contains a lot more active speed.
  • Speed can be very addictive, don’t take it regularly.
• Cannabis:
  • Use a filter in joints.
  • Smoking spliffs can increase the risk of cancer. Especially when mixed with tobacco.
  • Reduce the amount of tobacco you put in your joint.
  • Try and make one joint last a long time by keep putting it down between puffs.
  • Smoking pure cannabis is safer than mixing it with tobacco, but be careful not to smoke too much as a result.
  • Smoking a vaporiser has much less cancer risk and is better for the lungs, however be careful as it is easy to smoke too much.
  • Eating cannabis takes longer to come on and last longer. Be careful how much you eat.
  • If you use to come down from other drugs it will extend the comedown and can make you feel worse later.
  • Smoking hybrid/skunk has a higher level of THC which could impact negatively on mental health
• LSD:
  • Take LSD in a safe place, with people you trust.
  • Acid can sometimes take a long time to come up. If your tab doesn’t work don’t take another one, you may end up losing the plot.
  • If someone has a ‘bad trip’ talk to them about things that they like, remind them that it is the drug that is doing this to them and that it will end. Take them somewhere safe, quiet, and not too dark not too light.
• Magic mushrooms:
  • If you are going to pick them, take a mushroom identification guide. You could end up picking the wrong mushrooms and poisoning yourself.
  • Take mushrooms in a safe place, with people you trust.
  • Wash the mushrooms before you eat them. > Cook or heat them before you eat them.
  • Take a small dose first.
  • Don’t do it if you have a lot on your mind bothering you.
  • Also see all the safety measures for LSD
• Ketamine:
  • Don’t mix with other drugs or alcohol.
  • If you get bladder or stomach pains then stop taking ketamine and consult a doctor.
  • Do Ketamine in a safe place, you may become unaware of your surroundings and be a danger to yourself because you will not feel pain on ketamine.
  • Try and use ketamine with friends so they can look after you.
  • If injecting, use clean works.
  • Ketamine is more powerful per gram than other powdered drugs, so be careful how much you take. Take in small doses so you can see what effect it’s having on you.
  • Ketamine may cause vomiting, high doses could cause you to choke on your own vomit.
• Solvents:
  • Try and do solvents in a safe place with friends. If you pass out they can get help.
  • Don’t cover your head whilst inhaling / sniffing – it can suffocate you.
  • Use a small plastic bag, i.e. a crisp bag to inhale from.
  • If you are using aerosols it is less dangerous to spray them into a small bag first and then inhale.
  • Many solvents are flammable so be careful with cigarettes and flames – some may ignite if heated.
  • Try and avoid heavy exercise and shocks whilst using as this may stop your heart.
  • Try to take extra fluid such as vitamin C drinks or water.
  • Try to protect skin exposed to solvents by using Vaseline.
  • Try not to mix solvents and don’t use with other drugs, especially alcohol.
• Tranquillisers / Sleeping Pills / Benzodiazapines:
  • Don’t take them for more than a few weeks to relieve anxiety or to help sleep. If taken for too long they become ineffective but dependence develops.
  • Don’t mix with alcohol or other depressants such as heroin. Mixing increases the risk of overdose.
  • Use as prescribed and use the recommended dose.
  • Don’t inject. Cocaine:
  • Don’t share notes, straws, tubes etc. as you may contract blood borne virus’ from them.
  • Don’t take it if you suffer from hypertension, heart problems, epilepsy, liver damage, thyroid conditions, muscular disease or respiratory problems.
  • If snorting, use both nostrils to give each one a break.
  • Don’t drink alcohol whilst taking cocaine, the two drugs combine in your body and form a new and more dangerous drug; cocaethylene.
  • Take some time out from dancing to chill out and let your body rest.
  • Don’t wear hot clothing or gloves and hats whilst out clubbing. It makes dehydration and overheating more likely.
• Crack:
  • Re-wash crack yourself for cleaner rocks
  • Space your hits
  • Make sure you take in plenty of vitamin B complex (there is plenty in marmite) if you use crack.
  • Try not to re-smoke/re-cycle the crack left in a pipe.
  • Eat before you start using.
  • Use a glass pipe not a can or plastic bottle.
  • Use lip balm / vaseline to avoid cracked lips (be aware that vaseline damages condoms).
  • Do not share pipes with other people this can pass on Blood Borne Virus’ especially if you have cracked lips.
  • Avoid injecting crack – if you are going to, dissolve in cold water with a little vitamin C. Don’t heat it as this increases the chance of it re-crystallising inside your veins.
  • Don’t use other drugs to come down from crack as you can develop another addiction, particularly likely with heroin or alcohol.
• Heroin:
  • Never share works with anyone else. This includes spoons, needles, syringes, filters and water used to clean works.
  • Try to smoke rather than inject – there is less risk of overdose.
  • Don’t use lemon juice, get citric from needle exchange.
  • If you are unsure about the dangers and methods of injecting, get some professional advice and information.
  • If you re-use or share works then make sure that you clean them properly, boiling water is not enough to kill all bacteria and virus’
  • Always inject towards the body.
  • If you are injecting make sure that you are injecting into a vein.
  • Always clean your injection site before and after using.
  • Don’t use cotton wool as a filter, use filters from a needle exchange or cigarette filters if necessary.
  • Try and vary the sites you use.
  • If you have been substance free for a while your tolerance will have gone down and you are more likely to overdose. If you do use, use a small amount, not what you were used to before.
  • Don’t mix with methadone, alcohol, tranquilliser or other depressant drugs.
  • Be careful of batches of heroin where you don’t know the strength.

2.7 Identify the potential effects and difficulties that are likely to arise in attempting to cease or reduce substance use and the strategies/methods for alleviating them

The beginning of a substance abuse disorder is usually marked by a physical dependence. This can be recognised by a tolerance to and withdrawal symptoms from the substance of abuse. Tolerance occurs when one needs more of the substance to get the same effects as when initially started. When a tolerance is established, a person may experience withdrawal when they stop using the substance.

Withdrawal symptoms are severe and can include heart palpitations and seizures, depending on the type of drug used. The second part of an abuse disorder involves a psychological dependence on the substance. This is characterized by a subjective feeling that the user needs the drug to feel normal. There is often a desire to stop using the drug, as well as prioritization of its use over social and familial responsibilities.

As the potential effects and difficulties can be different depending on the substance (and quantities) abused, I will look at the most common I work with – alcohol – in detail below. People who drink heavily over an extended period of time develop a tolerance to alcohol. When this happens, an individual has to drink more and more to feel alcohol’s effects. Eventually, someone with a tolerance to alcohol can develop a physical and mental dependency on it. This means that a person must then constantly drink to prevent withdrawal. The symptoms of alcohol withdrawal can be intense and even deadly. Because of this, medically-supervised detox is always recommended for alcohol withdrawal. Symptoms of withdrawal can be psychological and physical. How much, how often and for how long someone consumed alcohol impacts their withdrawal symptoms. People who drink often and a lot experience the most extreme withdrawal symptoms.

Common symptoms include: depression, anxiety, headache, fatigue, nausea & vomiting, nightmares, shakiness, fever, irritability, insomnia, rapid heart rate, perspiration, changes in body temperature, restlessness, appetite loss, mood swings, disorientation, cognitive issues, weakness, and delirium tremens.

Whether or not an individual experiences alcohol withdrawal, and the severity of symptoms, is determined by a number of factors, including: genetics, metabolism, duration of alcohol abuse, severity of alcohol abuse, going “cold-turkey” vs tapering off, body weight, gender, age, underlying mental health concerns, abuse of other substances. The first symptoms of withdrawal usually appear within the first few hours after the last drink. Tremors or shakes are common first signs of withdrawal. In severe cases, seizures and hallucinations follow. Delirium tremens is the severe end of alcohol withdrawal that causes confusion, tremors and hallucinations. Delirium tremens are life-threatening. It can cause heart problems and fatal injuries from sudden seizures. Seizures may occur up to four days after stopping drinking. Physical symptoms taper off sooner than psychological ones do. Long-term effects can last for months or even years after the last drink. These may include sleep disturbances or lingering depression. Alcohol detoxification returns a heavy drinker’s system to normal after extended alcohol abuse.

People who have been drinking heavily for a long time may experience intense side effects from detox. It is important to detox from alcohol under the supervision of a medical professional. Medical detox ensures careful monitoring and supervised medication when needed. Although rare, some of the severe side effects of alcohol detox include heart arrhythmias, seizures, kidney or liver dysfunction, and hallucinations. Keeping the service users’ system in balance and preventing complications is a major part of alcohol detox. Sometimes prescribed medications from a medical professional are necessary to do this. Medications used during detox include drugs that prevent seizures, reduce cravings and treat co-occurring disorders. Benzodiazepines (namely Librium & Valium), are one type of drug that reduces psychological withdrawal symptoms, such as anxiety, and allow people to detox without therisk of seizure. Anticonvulsants or anti-seizure medications, such as Levetiracetam, may also be used, as can anti-craving medications like naltrexone or acamprosate. Detox is the first step in treating an alcohol addiction. We carry out home & ambulatory detoxes, or use approved inpatient facilities. After detox, ongoing structured treatment, therapy and support groups can help recovering alcoholics learn how to cope without alcohol.

Learning Outcome 3:- Be able to support individuals when they have used substances

3.1 Explain relevant policies and procedures for the support of individuals who have used substances

Health & safety policies and procedures are the agreed ways of working and approved codes of practice in health and social care settings relating to health & safety. The following points below are some of the Health & safety policies and procedures that we have to have in place at my service:

• What to do in the event of an emergency: dealing with accidents, injuries and emergency situations. This involves specific action to take, reporting procedures and completing relevant documentation.
• Dealing with first aid situations. This is the understanding specific hygienic procedures, how to deal with blood and other body fluids. I am a trained first aider. It is important that first aid kits are readily available and not locked away. It is necessary to have several first aid kits at various locations throughout the premises.
• Policies relating to specific working conditions and the working environment which comprises of understanding moving and handling individuals’ procedures.
• Where possible an appropriate environment to render First Aid or allow a person to rest (minor illness) should be provided. This environment should be private, allow access to hand washing facilities, drinking water and toilet facilities and should enable the casualty to sit or lie down as needed. Such facilities may be available where clinical rooms are provided.
• Policies relating to infection control and dealing hazardous substances. E.g. I am trained in using ‘spill kits’.
• Policies relating to security and personal safety. We have room alarms for taking into sessions, and protocols around lone working in clients homes.

To support service users who have used substances who attend the service, I follow our ‘Management of service users attending the service intoxicated’ procedure. Intoxication occurs when a person’s intake of a substance exceeds their tolerance and produces behavioural and/or physical changes. In order to effectively deal with an intoxicated service user one must first recognise that the signs and symptoms.

Formulation of a specific management strategy requires an understanding of the effects of different drugs on the central nervous system and subsequent changes in perception, affect, cognition and behaviour. This policy provides information on the signs and symptoms of intoxication and effective management of the situation. In the event of medical assistance being required in the service (intoxication, withdrawal, injury) I would follow the ‘First Aid at Work’ policy, and I am responsible for meeting my obligations under the Health and Safety at Work Act 1974, as set out in Section 7, which includes:

• To follow our health and safety policies.
• To be aware of procedures relating to first aid within the project.
• To use all personnel protective equipment (PPE) as provided.
• To complete our incident report in the event of any incident or accident where first aid has been provided.
• To maintain safe working practices and never take short cuts or chances.

There are other policies & procedures on best practice to deal with specific substance related situations that can occur. One example is our ‘Administration of naloxone as emergency aid’ procedure – to support service users with known or suspected opioid overdose be administered a naloxone injection.

Service users who present with symptoms such as loss of consciousness, snoring, blue lips, pinpoint pupils and who do not respond to painful stimuli should be managed using standard resuscitation procedures and then considered for naloxone injection. An ambulance should always be called. Any member of staff, volunteer, peer mentor or peer advocate who has received the appropriate training may administer naloxone as an emergency aid. Naloxone has an onset of action within two to five minutes following inter muscular administration. The dose may be repeated at intervals of two to three minutes to a maximum of 2mg (5 doses) if respiratory function does not improve. Since naloxone has a shorter duration of action than many opioids, close monitoring and repeated injections may be necessary according to the respiratory rate and depth of unconsciousness. Reported side effects of naloxone use include nausea, vomiting, sweating, increased heart rate, hyperventilation, increased blood pressure, tremulousness, ventricular tachycardia and fibrillation, pulmonary oedema, seizures and cardiac arrest. However, this should be balanced against use of naloxone in an emergency for the purpose of saving a life. When naloxone is used in the management of acute opioid overdose, basic life support measures should be used to support the management of the individual. This is likely to include placing the person in the recovery position. It will always include calling an ambulance. Naloxone may cause hypersensitivity reactions in susceptible individuals. Medical advice must be sought as soon as possible from a doctor if a recipient develops any signs of hypersensitivity. Pregnancy and pre-existing cardiovascular disease are listed as precautions for naloxone use but it is unlikely that this information would be available in the event of overdose. Service users who have responded to naloxone should be carefully monitored since the duration of action of some opioids may exceed that of naloxone. Administration of naloxone may precipitate an acute withdrawal syndrome, resulting in the person seeking further opioids. It is therefore important to wait with the person until the ambulance arrives.

3.2 Support individuals in a manner appropriate to the substance used, the effect which the substance has had and the condition of the individual

If a service user attends the project intoxicated the action taken will depend on the time they are attending, what they have ingested and when they ingested it.

In general intoxicated service users should be seen in the front room or reception area as their behaviour can be unpredictable and could put other service users or members of staff at risk. However in some cases the service user’s intoxication is not apparent until they have been taken into a session room. In some cases it may be necessary to see an intoxicated service user in which case I would assess the risks before seeing the service user. It may be best to see the person with a colleague. Where possible, alarms are carried at all times.

I always consider physical health issues that may present like intoxication e.g. hyperglycaemia / hypoglycaemia or head injury or recent seizure. Getting a urine sample from the service user can help to differentiate between drug induced intoxication and other causes of intoxication. However, I bear in mind that drugs remain in the urine for a number of days after they were last ingested.

If the service user appears intoxicated with alcohol (signs would include flushed skin, slurred speech, smell of alcohol and variable levels of consciousness) the points I note are:

• When did they last have a drink? If the service user drank a couple of hours ago they may actually be sobering up whereas if they drank 30 minutes ago they may get more intoxicated as time progresses.
• Have they had any other central nervous system depressant drugs? (Like heroin or methadone). If they have had something else there is a risk of overdose. It would be unwise to add anything else and it may be necessary to call an ambulance. If they are due to have prescribed medication that day and they have not had it yet I contact the pharmacist and either cancel it or ask them not to dispense before a given time.
• What is their breath alcohol level? The drink drive limit is 0.35mg/L breath alcohol (Breath Alcohol Concentration) or 80mg/ml blood alcohol concentration (BAC) and is understood to be the level at which complicated tasks and reaction times are significantly affected by alcohol. In terms of clinical impact alcohol dependent service users can present quite lucid with a BAC of 0.70mg/l. BAC readings must be interpreted in conjunction with the service user’s clinical presentation and a rough idea of when they had their last drink.
• Is this presentation out of the ordinary for that service user? Some service users consistently present in an intoxicated state as their levels of dependence make it unsafe for them to not have any alcohol. In some cases the service user always presents with a degree of intoxication. I must decide if this is out of the ordinary for that particular service user. Service users known to have alcohol dependence should be routinely breathalysed to give me an idea of a baseline breath alcohol level.

If the service user is intoxicated with opiates (signs would include sleepiness or drowsiness from which the service user is relatively easily roused, “pinned” pupils, and there may be signs of recent drug use like fresh blood stains if they are an injector) the points I note:

• When did they last use an opiate? Peak effects would happen within the first hour post dose depending on the route of administration and the particular drug. The effects would start to wear off after about 90 minutes.
• Is the opiate long acting? If they have use a long acting opiate like methadone then peak effects may take hours to appear.
• Have they had prescribed medication yet? If they have had illicit drugs plus their prescribed medication then there is a risk of overdose. The effect may be delayed. I check with the pharmacy that they have been collecting their medication. There may be some other reason for the intoxicated presentation.
• Why did they feel the need to use before an appointment? Are they finding they need to use something first thing in the morning in order to get through till they go to the pharmacy? Is the service user usually irritable and in withdrawal during your appointments? They may require a dose review or the facility to collect their medication before they attend (but I bear in mind they may forget to attend if they have their prescription before their appointment).
• Is this out of the ordinary for that service user? Is there any plausible reason for a sudden change in presentation? Has something happened to destabilise a once stable service user, or is this a common occurrence?

If a service user attending the service is / becomes highly intoxicated, overdoses or goes into withdrawal it can affect their ability to listen or communicate rationally therefore making communication poor or ineffective. I would use non-threatening nonverbal communication. The more a person loses control, the less they hear my words—and the more they react to my non-verbal communication. I am mindful of my gestures, facial expressions, movements, and tone of voice. I avoid overreacting. Remain calm, rational, and professional.

If the situation calls for it, as well as the presenting individual; I consider my own safety, that of colleagues and any other Service Users present. I assess the risks and deal with the situation myself only if it is safe to do so. I follow our service workplace protocols and try to keep risks under review in a dynamic situation. The below is not an exhaustive action advice list, but in addition to 3.1 above it gives a good general overview of support that I have previously given to service users:

• Emergency first-aid for ecstasy/stimulant-related heat stroke
• Get a paramedic or ambulance as soon as possible. Dial 999 and listen to the advice given whilst informing a senior member of staff immediately.
• Do not take the sufferer from one extreme of temperature to another. Rapid cooling may result in collapse and death. Take the sufferer to a cooler, but not cold, place unless they have sustained an injury and moving them may cause more harm. Use a fine water spray to cool the skin, keeping it moist whilst fanning strongly.
• Add a small amount of salt to the water. Wipe off any pools of water that collect with a towel.
• If the sufferer has to be moved to somewhere that is cooler, then protect their body by use of a blanket.
• Give cooled, pure orange juice. If this is not available, give water (with glucose or an electrolyte solution if possible). Moisten lips or give sips.
• Loosen hot/tight clothing
• Get help as quickly as possible when a sufferer begins to have fits.
• They have 10-15 minutes to stabilise their temperature before permanent damage occurs.
• If possible keep some of the drug that they have taken for poison testing later.
• If someone has collapsed or is having problems on drugs:
  • Stay calm and re-assure the victim.
  • Do phone for an ambulance, you won’t get arrested because of this.
  • Don’t change, their body temperature suddenly.
  • If possible keep some of the drug that the victim has taken for poison testing.
  • Check breathing and put the victim in the recovery position.
• Dealing with an Opiate Overdose
  • Call an ambulance
  • Check whether the person is conscious – pinching the ears if a good check.
  • Check if they are breathing, if not then start mouth to mouth and/or chest massage
  • Inject naloxone if available (see 2.6 above)
  • Put them in the recovery position.
  • Do not put them in a bath of cold water
  • Do not inject them with salt water
  • Do not give them stimulants
  • Do not walk them around.

3.3 Demonstrate how to make the environment as safe as possible, including how and when to move individuals for their own safety

Intoxicated service users should be treated with respect: I keep instructions simple and speak clearly, treat them in a quiet place if possible, and protect them from accidents. Overly intoxicated service users should be kept under observation until their intoxication diminishes.

We recognises that the environment that we project operate within and the service users accessing some of our services may require a more specialised direction on first aid training. Although H&S Regulations do not oblige employers to provide first aid for anyone other than their own employees, in the environment we operates within it is a sensible approach to include service users in assessment of first aid. We have therefore worked to develop a series of first aid courses specifically for front line workers in the following subject areas:

• First Aid for Front Line Workers.
• Needlestick Injury and BBV.
• Managing Body Fluid Loss, Clearing Body Fluid Spills and Dealing with Sharps Injury.
• Overdose Aid.

These courses are designed to provide confidence to staff, ensure risks and appropriate safe working practices are known and to ensure all staff know the appropriate action to take when faced with one of these scenarios. All projects are required to complete a First Aid Assessment, every six months to ensure that the level of first aid provision within the project is adequate. I am a trained first aider. If the service user experiences a seizure or otherwise becomes unconscious I clear the immediate area to prevent the person sustaining a head injury and place in the recovery position as trained. This is the only time I would move individuals for their own safety.

3.4 Support individuals to meet their own needs and requirements after the effects of the substance have worn off

If the service user appears intoxicated with alcohol, to support them to meet their own needs and requirements after the effects have worn off; my courses of action are:

• If there is time and this is realistic the service user can be asked to come back later in a more sober state.
• If there is no time the service user could be asked to attend the next day.
• The service user could be given a shorter prescription that starts the following day and asked to return for a review at a later date. This is the last resort if the first two options are not practical for a good reason, eg it was a Friday.
• The prescription could be given with guidance to the pharmacist not to dispense if intoxicated, but bear in mind most pharmacists will use subjective observations as they will not have a breathalyser.

If the service user is intoxicated with opiates and still due to have a prescribed medication that day, to support them to meet their own needs and requirements after the effects have worn off; my courses of action are:

• They go away and come back in a more fit state, if there is no time that may mean returning the following day.
• They omit the day’s dose and get a prescription starting the next day – this is a last resort for cases when the first option is not possible.
• In any case they will need a medical review as it may be that they are not held on the current dose.

As per our ‘Administration of naloxone as emergency aid procedure’ it is important that if naloxone has been used as an emergency aid and regardless of the individual’s response to treatment, they should be taken by the emergency services to A&E. If a service user declines the offer to attend A&E they should be advised of the high level of risk associated with not doing so. They should be given clear information of these risks to take away with them. In particular, they should be informed that the benefits of naloxone will wear off quickly and there is a strong possibility of a return to an overdose situation. They should be advised not to use any more illicit drugs and should not be alone for at least 12 hours. All reasonable attempts should be made by myself and colleagues to encourage the service user to attend emergency services

3.5 Show when and how to request further support and assistance

If a service user attends the project intoxicated the action taken will depend on the time they are attending, what they have ingested and when they ingested it, should be kept under observation until their intoxication diminishes, and if required (and consent permits) I may contact their next of kin. I will always call for an ambulance (999) if:

• they have fallen or injured themselves, particularly a head injury
• they have trouble breathing
• have any chest pains
• are over sedated
• they become confused
• they begin hallucinating, seeing or hearing things that are not there
• the person has a seizure
• any situation requiring the administration of naloxone

I have had instances of service users attending the service intoxicated with the intention to operate a motor vehicle after their appointment. If the service user has driven to the project, I encourage them to leave their car keys and return to collect them when in a fit condition to drive. The keys are signed by two members of staff and kept in the safe and the manager informed.

If the service user refuses to hand over the keys, they are be informed that the police will be called as they are in danger to themselves and other road users. The police are contacted if the service user insists in driving. If a service user attending the service has children in their care while intoxicated, I should notify management as this is an immediate child protection issue. The situation will be assessed and the service user offered any appropriate and available support for optimising safety for the child/ren; such as offering staff support in minding the children whilst on the premises, offering to contact another care-giver to support the service user.

3.6 Report information about episodes of substance use to an appropriate person and record it in the required format

If a service user attending the service has children in their care while intoxicated, in addition to the above management notification and support; I will refer to local children social services, which is done online by an online single point of access. SPA is a multi-agency service managing referrals for my region. The SPA service includes agency representation from statutory Children’s Services, NHS Health Visitors, Police and Child Adolescent Mental Health Service. All agencies represented within the SPA have access to the central database and share relevant safeguarding information. Unless it is judged to increase the risk to the child, I would inform the service user that I am making this referral. In all instances where a medical response has been given to an individual, an Incident Notification Form must be completed and submitted via a web-based incident reporting system and forwarded to our Health and Safety Co-ordinator as soon as possible (within 1hr where possible). Full details of our incident report procedure can be found in the ‘Incident and Accident Manual’ on our intranet. It is the Project Manager’s responsibility in line with the Incident Reporting procedure to report any incidents or near misses immediately to the Health and Safety Coordinator. It is a key component of any incident or accident investigation that lessons should be learnt, and appropriate action plans be drawn up. These action plans must include the person responsible for the action as well as a target date for completion.

Learning Outcome 4:- Be able to support individuals in reducing substance use

4.1 Assist individuals who have made a commitment to reduce substance use to review their reasons for doing so

The purpose of services such as where I work is specifically to support service users in changing their behaviours – namely to reduce substance use and learn & utilise new coping strategies in the effort of recovery and rehabilitation.

There is a variety of different approaches and methods I use when attempting to support service users in reducing their substance use, the primary of which are cognitive behavioural therapy (CBT) and motivational interviewing (MI). Our structured interventions / treatment utilises a range of proven evidence-based technologies; Cognitive Therapy, Behavioural Therapy and Cognitive Behavioural Therapy (CBT) are the principal theoretical cornerstones of our group interventions and therapeutic program.

National Institute of Health and Care Excellence (NICE) guidelines clearly affirm CBT’s efficacy in a range of mental health disorders; CBT-based Node Link Mapping is used extensively by colleagues & I within group settings and keyworking sessions. CBT is a form of talking therapy that combines cognitive therapy and behaviour therapy. It focuses on how service users think about the things going on in their lives, their thoughts, images, beliefs and attitudes (their cognitive processes), and how this impacts on the way they behave and deal with emotional problems. It then looks at how they can change any negative patterns of thinking or behaviour that may be causing them difficulties. In turn, this can change the way they feel. CBT may focus on what is going on in the present rather than the past, but may also look at the service users past and how these experiences impact on how they interpret the world now, thus assisting them in reviewing their reasons for their commitment to reduce substance use.

Cognitive and behavioural based relapse prevention interventions – develop the service users’ abilities to recognise, avoid or cope with thoughts, feeling and situations that are triggers to substance use. They include a focus on coping with stress, boredom and relationship issues and the prevention of relapse through specific skills, e.g. drug refusal, craving management. They can be delivered in group or individual format and may involve the use of mapping tools. They require additional competences for the practitioner and delivery within a clinical governance framework including appropriate supervision.

Motivational Interviewing is used extensively throughout my practice and is a prominent component of our pre abstinence structured interventions / treatment, where developing motivation in order to prepare and initiate journeys of recovery is a priority.

Giving person-centred, pro-motivational feedback rather than a confrontational feedback during interventions was recognised as having a positive impact on drinking outcomes by Miller inter alia in 1993. Subsequently, Motivational Enhancement Therapy/ Motivational Interviewing has been recognised as particularly beneficial to those who are resistant to treatment for substance misuse & addiction. The concept of MI evolved from experience in the treatment of problem drinkers, and was first described by Miller (1983) in an article published in ‘Behavioural Psychotherapy’. The fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures.

MI is a semi-directive, client-centred counselling style for eliciting behaviour change by helping service users to explore and resolve ambivalence. Compared with non-directive counselling, it is more focused and goal orientated. MI is a method that works on facilitating and engaging intrinsic motivation within the service user in order to change behaviour. The examination and resolution of ambivalence is a central purpose, and the practitioner is intentionally directive in pursuing this goal. MI recognises and accepts the fact that service users who need to make changes in their lives approach treatment at different levels of readiness to change their behaviour. Pre-treatment some may have thought about it but not taken steps to change it; while some especially those voluntarily seeking treatment, may be actively trying to change their behaviour and may have been doing so unsuccessfully for years.

In order for a practitioner to be successful at MI, four basic skills should first be established: the ability to ask open ended questions, the ability to provide affirmations, the capacity for reflective listening, and the ability to periodically provide summary statements to the service user.

MI is non-judgmental, non-confrontational and non-adversarial. The approach attempts to increase the client’s awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behaviour in question.

Alternately, I help service users envision a better future, and become increasingly motivated to achieve it. Either way, the strategy seeks to help them think differently about their behaviour and ultimately to consider what might be gained through change. MI focuses on the present, and entails working with a service user to access motivation to change a particular behaviour, that is not consistent with a client’s personal value or goal.

Warmth, genuine empathy, and unconditional positive regard are necessary to foster therapeutic gain (Rogers, 1961) within motivational interviewing. Another central concept is that ambivalence about decisions is resolved by conscious or unconscious weighing of pros and cons of change vs. not changing (Ajzen, 1980). It is critical to meet service users where they are and to not force them towards change when they have not expressed a desire to do so.

Motivational interventions – these aim to help service users resolve ambivalence for change, and increase intrinsic motivation for change and self-efficacy through a semi-directive style and may involve normative feedback on problems and progress.

They may be focused on substance specific changes and/ or on building recovery capital. Motivational interventions can be delivered in group or individual format and may involve the use of mapping tools. Motivational interventions require additional competences for the practitioner and delivery within a clinical governance framework including appropriate supervision. Motivational Interviewing and Motivational Enhancement Therapy are both forms of motivational interventions.

4.2 Offer support to individuals which respects their individual rights, and is appropriate to their needs

It is important that I ensure my interaction with service users is in a manner which recognises & respects their rights in making decisions regarding their use of substances, making decisions regarding their health, including their right to ignore advice, is appropriate to their needs, and is realistic within the limits of the resources available.

I do this by offering & providing person-centred support that is focused on the service user and their needs. We are all individuals and just because two people might have the same condition – it does not mean that they require the same support. To promote and provide person centred care and support I develop a clear understanding about the service users I am working with, including their needs, wishes, culture, preferred means of communication, likes and dislikes, their family & other professionals’ involved in their lives, and focus on enabling them to be in control of their life including how they want to live it, and plan for the support they would like (including changes that may arise in the future).

Person centred is not just about consulting a service user about their care, it is also about them taking control of the planning and delivery of their own support and care services. It is therefore important that person-centred values must influence all aspect of health and social care work. The following are some of the person-centred values which I practice – leading to the provision of safe and effective care and support:

• Individuality – This is treating the service user as an individual.
• Rights – Making sure the service users I support understand & access their rights and supporting and encouraging them to understand what they are entitled to.
• Choice – Supporting, encouraging, empowering and enabling a service user to make their own choices and decisions. Making sure thorough information is given and understood in order to make informed choices themselves, with me acknowledging the benefits of their choices.
• Privacy – Showing respect for an service user’s personal space and personal information and allowing them their privacy.
• Independence – This is supporting the service user to be as independent as possible. I endeavour to enable them to do things that they can do (or almost do) for themselves, rather than do things for them because it is quicker. This allows them to feel in control of their lives and gives them an increased sense of self-worth. It also means assessing the risks that they face but ensuring that they understand these.
• Dignity and Respect – This is a recognition of their intrinsic values regardless of circumstances, by respecting their uniqueness and their personal needs.
• Partnership – Working in partnership with other professionals, colleagues, families and partners is an essential part of me providing support. Person-centred support is about a whole range of people working together to improve the life of a service user. Partnership is all about the service user I am supporting, and all of the partners involved will need good communication, sharing appropriate information putting the service user’s best interests at the centre of everything that everyone does.
• Compassion & Care – Providing support in a way that is consistent, sufficient and meets the needs of the service user. Providing care to them in a way that shows kindness, consideration, empathy, dignity and respect using the right values and behaviours.
• Courage – Providing care in a way that is morally acceptable, do the right thing for the service user, and to constantly develop and change my ways of working to more efficient practice. Speaking up if I have concerns about practice at work or about an service user.
• Communication – This is key to providing high quality support and to effective team working. It includes actively listening to what the service users have to say and is necessary for building strong relationships with them, partners involved in their care, and my colleagues. This allows me to find out more about their unique likes, dislikes, abilities and preferences and I can tailor there care to meet their requirements. This shows service users that I respect and value them. It will show I have a genuine interest in them and that I care.
• Competence – Having the knowledge, skills and expertise to provide high-quality support, working effectively and efficiently with service users. Working in this way ensures I are meeting the expected standards.

4.3 Assist individuals to review their progress in reducing substance use

The primary method I use in keyworking sessions to assist service users to review their progress in reducing substance use, realistically assess their achievements, and identifying opportunities for improvement; is in the regular and effective use of their service user plan (SUP), the aforementioned integrated risk and recovery plan which provides a central place to record the ongoing assessment, review and management of goals, risks and actions.

There are eight domains in a SUP, one of which is specifically for substance use. There are two types of ongoing review that are utilized collaboratively by the service user and practitioner to create & update the SUP: > Service User Plan review (SUPR): This is a regular review to be undertaken at each contact with the service user and it focuses on the areas that are relevant to the service user, that is, where any goals (i.e. reduction) or risks (i.e. barriers to that reduction) have been identified. > Full risk review (FRR): This requires an exploration of all areas and to complete this each of the eight domains must be commented on, the time frame for the FRR is 12 weeks.

All reviews are dated & recorded on our system and once saved cannot be amended. When opening a new review throughout the treatment journey it pulls through the ‘risk indicators’, ‘protective factors’, ‘completed actions’ and ‘outstanding actions’ for each domain so the effectiveness of the action (i.e. considered & planned substance reduction) is carefully re-examined and the progress reviewed. The secondary assessment method I use in keyworking sessions to assist service users to review their progress in reducing substance use; is again the Treatment Outcome Profile (TOP) which provides a useful baseline to measure (amongst other things required by the National Drug Treatment Monitoring System – NDTMS) their specific substance use. It is useful to track changes in key areas and feed this back to the service user to monitor progress and stimulate ideas for new plans. Our system has the facility for using the information to generate a graph / map providing a visual record of changes, which can be easier to understand and have more impact on the service user than a list of numbers.

4.4 Describe how to manage your own feelings about the individual’s progress or lack of this in such a way as to minimise their impact on the support provided

Reflective practice is a continuous and critical aspect of my role – which entails I am continually striving to monitor & improve the support I provide – by considering my own feelings around the progress or stuckness of the service users with whom I’m working, and examining how I can ensure this does not negatively impact the relationship / work being carried out, maintain or offer more effective high quality support.

Showing that I can reflect on practice involves developing the following skills and qualities:

• Self-awareness: how my behaviours impact on individuals, others and my work.
• Honesty – being honest with myself about how I feel about individuals, situations or actions, and maintaining a positive attitude.
• Commitment: striving to improve the quality of my work.

There are two different methods I can use for reflecting on my practice:

• Reflecting on a work activity after it has happened – learning from the experience and then taking the necessary actions for making improvements if needed.
• Reflecting on a work activity and take the necessary actions for making improvements while it is happening.

Supervision gives me protected time with my manager that focuses solely on how I am managing with my day-to-day responsibilities, share my feelings about individual’s inc their progress and discuss what can be done to manage these. The client facing team members of my service have a monthly group clinical supervision session with an outside clinical supervisor where we discuss issues and challenges with service users. It improves feelings management, encourages dissemination of good practice & shared learning, and provides motivation, innovation and job satisfaction.

Regarding immediate or ‘in the moment’ support around managing my feelings and their impact on my practice – my line manager (the Deputy Services Manager) or their line manager (the Service Manager) would usually be my first sources to approach. There may also be a colleague that I may approach who knows me well or who has been in a similar situation and therefore understands how I am feeling. Through my organisation I also have access to an EAP which can provide short term solution focused counselling, legal support, and signposting to other appropriate support services.

4.5 Identify the specialist agencies and support networks involved in supporting substance users

Mutual aid support networks I have supported service users to access include:

• SMART Recovery Any mood altering substance or addictive behaviour – www.smartrecovery.org.uk / 0845 603 9830
• Alcoholics Anonymous (AA) for alcohol – www.alcoholics-anonymous.org.uk / 0845 769 7555
• Cocaine Anonymous (CA) for cocaine and other mood altering substances – www.cauk.org.uk / 0300 111 2285 or 0800 612 0225
• Drug Addicts Anonymous (DAA) for any mood altering substance – www.drugaddictsanonymous.org.uk / 0300 030 3000
• Marijuana Anonymous (MA) for any form of cannabis – www.marijuana-anonymous.co.uk / 07940 503438
• Narcotics Anonymous (NA) for any mood altering substance – www.ukna.org / 0300 999 1212
• Social Services
• Community Signposting Service
• Carers Hub
• Single Point of Access Single point of access
• Community Police