Production, Ratification, Implementation and Review of Policies & Procedures - GG/CG/05
POLICY /PROCEDURE:
10th September 2007
NATURE AND SCOPE:
TRUST WIDE POLICY AND PROCEDURE
GROUP: General Governance & Clinical
SUBJECT: The Management of risks with clients who have co-occurring mental
health and substance misuse problems.
This policy details …….
Risk assessment in relation to substance misuse (drugs and alcohol) for those individuals
who also experience mental health difficulties.
The following section to be completed after the document has been ratified by
Executive Leadership Team (ELT)
DATE OF LATEST RATIFICATION:
RATIFIED BY:
IMPLEMENTATION DATE:
ASOCIATED TRUST POLICIES
AND PROCEDURES:





RISK ASSESSMENT AND MANAGEMENT OF RISK TRAINING POLICY.
(CL/CP/15).
SEARCHING PATIENTS, VISITORS & THEIR PROPERTY (CL/CP/17).
PROTECTION OF VULNERABLE ADULTS (CL/CP/16).
MANAGEMENT OF ALCOHOL AND DRUG USE BY SERVICE USERS/VISITORS
ON TRUST PREMISES (CL/CP/26).
CARE PROGRAMME APPROACH POLICY (CPA) IN PARTNERSHIP WITH
SOCIAL SERVICES DEPARTMENTS IN NOTTINGHAMSHIRE (CL/CP/07).
Issue Number/Date
To be shown on bottom left hand side of every page.
Title & Number Of Policy /Procedure
To be shown on top of right hand side of every page.
NOTTINGHAMSHIRE HEALTHCARE NHS TRUST
Management of risks with clients who have co-occurring mental health and substance
misuse problems
CONTENTS
1.0
Introduction
2.0
Policy Principles
3.0
Definitions
4.0
Duties
5.0
Implementation
6.0
Training
7.0
Target Audience
8.0
Review Date
9.0
Consultation
10.0
Relevant Trust Policies
11.0
Monitoring Compliance & Effectiveness
12.0
Equality Impact Assessment
13.0
Legislation Compliance
14.0
Champion & Expert Writer
15.0
References /Source Documents
Appendix 1 Additional Dual Diagnosis Risk Assessment Summary and Management Plan.
Appendix 2 Drug interactions matrix
Appendix 3 Risk matrix
Appendix 4 Record of Changes
Appendix 5 Record of Employee Having Read the Policy
1
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Issue Number/Date
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Title & Number Of Policy /Procedure
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NOTTINGHAMSHIRE HEALTHCARE NHS TRUST
Management of risks with clients who have co-occurring mental health and substance
misuse problems
1.0
INTRODUCTION
1.1
There is a considerable increase in risk to service users and others if they are taking
drugs or drinking alcohol excessively. The consumption of certain drugs, particularly
stimulants (i.e. cocaine, crack or amphetamines) may lead to a level of dis-inhibition that
increases potential for aggression, violence or self-harm. Heroin and other opiates pose a
significant risk of overdose especially if taken in combination with alcohol or
benzodiazepines. Methods of ingestion of drugs also increase their risk, for example injecting
drugs increases risk of overdose, blood borne infection, physical health problems and
accidental injury to service users and visitors. Other drugs, particularly volatile substances
(gas, glue, petrol etc) have been linked to a high level of accidental death or accident when
the client is intoxicated. Excessive alcohol consumption has been linked to higher levels of
domestic violence, accidents and physical health problems.
This client group tends to be predominantly made up of young men, who have a greater
potential for violence, self-harm and suicide, combined with easy access to highly toxic
substances significantly increases their risk. Standard risk assessments do not always
address substance misuse as a significant risk but it is clear that it warrants further and more
thorough investigation.
The full risks of substance misuse and combined mental health problems are too complex to
outline here and should be assessed on an individual basis taking into account all biopsychosocial factors.
It is important to note that it is possible to effectively manage all risks that service users pose
so long as it is based upon accurate information gathering and collaborative planning with
the service user, carers and other service providers. It is not acceptable to dismiss increased
risk as an issue that services cannot tackle due to a lack of specialist knowledge. Specialist
services support is available to service providers to facilitate accurate risk assessment and
planning. It is also important to remember that though a practitioner may regard certain
behaviour as high risk, service users and their carers may be quite used to coping with (or
minimising) such risks on a day to day basis.
The Mental Health Policy Implementation Guide; Dual Diagnosis Good Practice Guide (DH
2002) states that:
“Routine risk assessment protocols need to address specific factors relevant for individuals
with a dual diagnosis. The severity of substance misuse, including the combination of
substances used, is related to the risk of overdose and/or suicide. Exploration of the possible
association between substance misuse and the increased risk of aggressive or anti-social
behaviour forms an integral part of the risk, and should be explicitly documented.”
2.0
POLICY/PROCEDURE PRINCIPLES
2.1
There is a need to address specific risks with this client group in three main areas:

Risk of accidental/intentional overdose, physical harm and suicide potential, due to
substance misuse. This should include risk related drug taking behaviour (i.e. injecting
drugs or opportunistic and experimental drug taking). The issue of abuse/violence from
drug dealers or other people associated with their drug taking should also be specified.
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Issue Number/Date
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Title & Number Of Policy /Procedure
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
Risk of self-neglect directly resulting from substance misuse and its associated lifestyle.

Risk to others due to aggression and violence. Potential aggression or violence from
the client or and/or risk due to accidental harm (i.e. needle stick injuries). Included in this
should be an assessment of risk to community practitioners who visit the client from other
people who associate with the client (i.e. other drug users or dealers)
Many of these specific drug related risk issues are not covered in standard risk assessment
policies. The attached addendum (over leaf) is a suggested addition to existing CPA risk
assessment policies.
3. ADDRESSING THE NEEDS OF THIS CLIENT GROUP:
3.1. GENERAL:
 All service users should have a CPA risk assessment/management plan.

Where a client scores 1 or more on the Health of the Nation outcomes (HoNos) question
detailing problematic drug/alcohol taking the CPA key-worker has responsibility for
completing the form: Additional Dual Diagnosis Risk assessment and a
subsequent risk management plan which should be shared with the multi
disciplinary team involved in the client’s care.

Ensure all new assessments consider the possibility/role of substance misuse.
3.2. ASSESSMENT:
 Information from other services involved in the service user’s care is an important
determinant of risk. In particular risk history and any factors detailed in the wider CPA risk
assessment are very useful.

Conduct assessment of new clients with another practitioner. Or ensure that it is
completed in a location where the safety of the assessor can be checked on by
administrative staff or other practitioners.

If an assessment is to be conducted at the client’s home make joint visits.

Only make solo home visits to clients, if a lengthy assessment has established that there
is minimal risk to the practitioner, and ensures that there is clear indication in jointly held
team diaries and/or in-out boards of the practitioner’s whereabouts and time of return.

Conduct home visit assessments (and subsequent visits if the risk assessment
indicates) in the middle part of the day NOT early in the day or right at the end of a shift.
Teams should establish a system of checking in by phone with admin staff or other
practitioners when visits to these clients have been completed.

Instigate the trust lone-worker policy.

Curtail visits if the client appears excessively intoxicated (bearing in mind any
immediate risk to the client).

Consider any further involvement from emergency services or later follow up from the
supervising team.
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Issue Number/Date
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Title & Number Of Policy /Procedure
To be shown on top of right hand side of every page.
3.3. COMMUNICATION & INFORMATION:
 Communicate regular evaluations of risk assessments and risk related care plans to
the whole of the MDT including client and carers as appropriate.

Key-workers should engage all service users with dual diagnosis in a process of harmminimisation. ensuring that they have appropriate ways to dispose of injecting equipment
(i.e. by supplying them with cin-bins).

Ensure that clients who are known opiate takers (i.e. Heroin, methadone etc) receive
overdose warning information in writing AND verbally (available from the dual diagnosis
team). PARTICULARLY THOSE INDIVIDUALS WHO ARE KNOWN DRUG TAKERS
DISCHARGED FROM IN-PATIENT AND RESIDENTIAL FACILITIES as there is a
significant risk of overdose due to their recent period of abstinence.

Obtain regular urine samples from clients to ensure that an accurate indication of drugs
consumed and patterns of substance misuse are determined. This will help establish
areas and possible patterns of acute risk. Drug screening also allows the client and
practitioner open opportunities to discuss substance and mental health associated risk
which keeps the topic ‘live’.
3.4. EVALUATION:
 Regularly evaluate clients prescribed medication to ensure that the risk of interactions
(refer to interactions information sheet) and accidental overdose is minimised (i.e. be
aware of the dangers of benzodiazepines and alcohol)
3.5 PROCESSES FOR JOINT WORKING.
The implementation of interventions for people with dual diagnosis will be implemented in an
integrated manner in line with national policy. This means that all services have the
responsibility to conduct risk assessments in line with this policy as appropriate. Services will
be supported by specialist dual diagnosis services to implement this policy and to gain the
necessary skills in order to be able to complete risk assessments. Joint integrated care
pathways, which include risk assessment as outlined in this policy, are advocated in the
Nottinghamshire partnership dual diagnosis strategy and involve services across the health
and social care spectrum including third sector partners.
4.0
DEFINITIONS
4.1
The term “Dual diagnosis” is commonly used to describe individuals who have coexisting mental health and substance misuse difficulties
5.0
DUTIES
5.1
6.0
IMPLEMENTATION
6.1
10th September 2007.
7.0
TRAINING
7.1
Training implications arising from this policy are covered in the attached training
mapping grid.
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Issue Number/Date
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Title & Number Of Policy /Procedure
To be shown on top of right hand side of every page.
8.0
TARGET AUDIENCE
8.1
All staff working in substance misuse, mental health services and learning disability
services.
9.0
REVIEW DATE
9.1
Annually from 10th September 2007.
10.0
CONSULTATION
10.1
All clinical areas have been consulted across the trust via the clinical directors.
11.0
RELEVANT TRUST POLICIES





RISK ASSESSMENT AND MANAGEMENT OF RISK TRAINING POLICY.
(CL/CP/15).
SEARCHING PATIENTS, VISITORS & THEIR PROPERTY (CL/CP/17).
PROTECTION OF VULNERABLE ADULTS (CL/CP/16).
MANAGEMENT OF ALCOHOL AND DRUG USE BY SERVICE USERS/VISITORS
ON TRUST PREMISES (CL/CP/26).
CARE PROGRAMME APPROACH POLICY (CPA) IN PARTNERSHIP WITH
SOCIAL SERVICES DEPARTMENTS IN NOTTINGHAMSHIRE (CL/CP/07).
12.0
MONITORING COMPLIANCE AND EFFECTIVENESS
12.1
An annual audit in partnership with Trust risk assessment leads will be conducted.
The Nurse Consultant in dual diagnosis for the trust has lead responsibility for the
audit and its reporting to the trust risk assessment board.
12.2
Content of audit reports: Audit reports will utilise information gained from a sample
of client notes across trust services to establish if risk assessments in line with this
policy have been completed where appropriate. The Trust serious and untoward
incidents process will ensure that at SUI reviews risk assessments relating to this
policy are taken into account and reviewed where the SUI pertains to drug or alcohol
related incidents.
12.3
Criteria for audit: Clients records will be audited for:
 The existence of a risk assessment and management plan in line with this
policy, where appropriate.
 Appropriate care plans and the delivery of interventions which address the risk
associated with substance misuse.
 Delivery of information to clients on drug use in-particular overdose warning
information where appropriate.
12.4
Arrangements for the development and review of action plans: Issues arising
from the audit of this policy and risk assessments associated with SUIs will be
reviewed by the trust risk assessment leads and reported via the trust risk
assessment board for further action and to monitor the effectiveness of this policy.
Appropriate amendments and lessons learned will be communicated to clinicians in
order to ensure that this policy continually evolves in line with client need and service
provision.
5
All pages to be numbered in sequence
at bottom of page (centre).
Issue Number/Date
To be shown on bottom left hand side of every page.
Title & Number Of Policy /Procedure
To be shown on top of right hand side of every page.
13.0
EQUALITY IMPACT ASSESSMENT
14.0
LEGISLATION COMPLIANCE
14.1
This policy was written within the context National Service Framework for Mental
Health (1999), NTA Models of Care (NTA 2002), Dual Diagnosis Good Practice
Guidance (DH 2002) and complies with the following legislation: Misuse of Drugs Act
1971, Drugs Act 2005.
15.0
CHAMPION AND EXPERT WRITER
15.1
The Champion of this policy is, Simon Smith Executive Director for local services.
The Expert Writer is Dave Manley Nurse Consultant in dual diagnosis
16.0
REFERENCES /SOURCE DOCUMENTS
16.1
Department of Health (1998). Tackling Drugs to Building a Better Britain.
Government 10-Year Strategy for Tackling Drug Misuse.
The
Department of Health (1999). National Service Framework for Mental Health.
Department of Health (2002). Dual Diagnosis Good Practice Guidelines.
Phillips, P. (2000). Substance misuse, offending and mental illness.
Journal of Psychiatric and Mental Health Nursing, 7, 483-489.
Safer Services – National Confidential Inquiry into Suicide and Homicide by
People with Mental Illness. Report 1999 – Summary.
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Issue Number/Date
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Title & Number Of Policy /Procedure
To be shown on top of right hand side of every page.
APPENDIX 4
Policy/Procedure for:
Management of risks with clients who have co-occurring mental
health and substance misuse problems.
Issue:
Status:
Author Name and Title:
David Manley, Nurse Consultant in Dual Diagnosis.
Issue Date:
10th September 2007
Review Date:
10th September 2008
Approved by:
Distribution/Access:
RECORD OF CHANGES
DATE
AUTHOR
POLICY/
PROCEDURE
DETAILS OF CHANGE
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Issue Number/Date
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Title & Number Of Policy /Procedure
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APPENDIX 2
EMPLOYEE RECORD OF HAVING READ THE POLICY/PROCEDURE
Title of Policy/Procedure:
I have read and understand the principles contained in the named policy/procedure.
PRINT FULL NAME
SIGNATURE
8
DATE
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at bottom of page (centre).
Issue Number/Date
To be shown on bottom left hand side of every page.