A DRUG DEPENDENCE UNIT WITHIN A HOSPITAL IN CANBERRA

KeJth Powell

The alcohol and drug dependent services in the ACT comprise two Capital Territory Health Commission (CTHC) units, one operating outside the hospital service and one func- tioning within the hospitals,

The unit outside the hospital consists of five people and is structured within the mental health division of the CTHC. It has the responsibility of coordinating services within the ACT, which involves maintaining close contact with voluntary agencies and other sections of the CTHC (such as health education and therapeutic communities). It is directly con- cerned with formulating policy and maintaining contacts throughout the community, both medical and non-medical. However, it also provides a primary therapeutic assessment and counselling service for drug dependent people.

The hospital-based drug dependence unit (DDU) comprises four people: a typist/secretary, a registered nurse, a social worker and a physician. It became fully operational in July 1979. Its operational tie is to the hospital medical superinten- dent, and thus to the CTHC. At its commencement, no guide- lines to follow were available, and that had advantages and disadvantages. The unit is run as an outpatient unit and does not have access to beds. However, if a bed is needed for a patient the procedure has been to admit that patient under the care of the physician-of-the-day. Most such admissions have been primarily to cover detoxification for alcohol, or for management of an alcohol-related physical disorder.

The two main drugs dealt with are alcohol and heroin. For the latter there is a small methadone maintenance program, though this is presently under review. The number currently using methadone maintenance is 16. Additionally, about 20 clients each year are detoxified from illicit drugs (mostly heroin), using methadone on a reducing scale usually over 4-6 weeks on an outpatient basis. Many heroin users who present to the DDU are denied methadone maintenance and encour- aged to deal with the problem by means other than using drugs (e.g. Karralika, WHOS, Odyssey, or abstinence with counsel- ling).

Providing a service such as methadone maintenance or methadone detoxification is time consuming and emotionally trying to all involved. In any small DDU being set up in a hospital careful consideration should be given to this issue: it can be argued that the yield is not worth the time and energy put into it. While the need or value of a methadone maintenance program may be debatable, there is considerably less doubt about the value of methadone to detoxify patients on an outpatient basis - - it is probably appreciably cheaper than admission to hospital for such a program.

It is appreciated that simple detoxification seldom produces long-term abstinence. It does, however, given the person time to think about the consequences and to enter a treatment program (e.g. a therapeutic community) in a drug-free state, it also enables him/her to survive a crisis situation. Further, it is a situation that may lead to more substantial contact at a later date.

As alcohol is the major drug that the DDU deals with, the time spent with the heroin user is disproportionately high. Despite its limitations, methadone use may have a legitimate place in a DDU. The difficulty is the diversion of time and talent and, in a major city such as Melbourne or Sydney, people allocated to methadone can be treated in clinics especially designed for that purpose. This is probably not the case for base hospitals. Certainly, for the ACT methadone will only be given in the

hospital, and this is an imposition not seen in a teaching hospital. In essence a universal blueprint is not available and each unit will develop to meet the needs of that local.

Basic Data of DDU

With respect to the patients seen at the DDU, a brief intro- duction is given in Tables 1-4. Table 1 shows that in 1980-81 we saw 242 new patients; 67% in trouble with alcohol. For the principle sources of referral, Table 2 shows the hospital as the major source for alcohol (56%), while serf-referrals dominate for illicit drugs. While we do get people under the age of 20 attending with alcohol problems, the most common age for alcohol users is, as shown in Table 3, the 30-39 years old group. For illicit drugs most users are aged 20-29.

Table 1: New clients 1980-81

Alcohol 161 67% Illicit drugs 57 23% Polydrug and other 24 10%

N = 242 100%

Table 2: Source of referral - - last 100 admissions

Illicit Total Alcohol Drugs

Hospitals (W.V.H., Royal Canberra Hospital, Calvary) 46 56.0% 3.0%

General practitioners 14 21.0% 27.0%

Self 22 13.5% 43.0%

Other Agency 10 5.0% 21.5%

Legal 5 3.3% 5.5%

Family/Friend 3 1.2% - -

N=100 %=100 %=100 N= 61 N= 37

Table 3: Age & s e x - last 100 admissions

Alcohol (N=59) Illicit Orugs (N=37) Age per cent per cent

20 8.1 20-29 18.5 73.0 30-39 37.5 16.2 40-49 23.5 50-59 17.0 2.7 60+ 3.5 -,

100.0 100.0

Sex

Male Female

75 25

100.0

60 40

100.0

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Table 4: Methadone maintenance

AtDe¢.T9 At Dec.80 AtJuly81

No. on program 7 12 17 Total no. commenced 23 No. f in ished-- outcome of: 7

1 - - alcoholic hepatitis 1 - - drinking 2 - - going well 1 - - NSW methadone program 2 - unknown

With respect to methadone use, a slow escalation is shown in Table 4. This is not to be interpreted that heroin use within the ACT has also steadily increased. There is no evidence for or against this. It more likely reflects the fact that, especially in the first year of operation, the facility of methadone maintenance was not encouraged.Indeed, its role is continuously subject to mutterings of ill-will and some would like to see it disbanded. If we had more viable substitutes, such disquiet would be accep- table. The use of methadone as a means of detoxitying is also increasing, but it is not cost effective as a method of dealing with the basic problem of drug abuse. Perhaps the same may be said for detoxitying heavy drinkers. In essence itis a service we are obliged to provide.

AIMS

The aims of the unit are to: 1. provide a service within the hospital such that, eventually,

all patients with an alcohol or drug-related problem who enter the hospital are considered for referral to the unit. Those seen in the unit are assisted through counselling, mostly one-to-one;

2. break down the belief that nothing can be done for such patients - - an attitude that has in the past been reinforced by the lack of facilities for referral;

On this point, I believe hospitals such as ours need, in casualty, a facility for keeping people up to 24 hours, prior to either admitting or discharging. This would ensure that some who have only minor physical problems, such as alcohol withdrawal or toxic hallucinosis, or who are heavily intoxicated and homeless, can be kept overnight. This is not synonymous with provision of a refuge for heavy drinkers. The expense would be justified by the saving made with respect to admissions. However, it is an area that needs to be researched to justify it on economic grounds.

3. provide a facility for physically assessing any patient with an alcohol/drug problem, especially if the drinking has led to possible sequelae;

This includes assessing whether a person is undergoing physical withdrawal, which would exclude him/her from a therapeutic community. It also allows the occasional heavy drinker to be detoxifed on an OPD basis. This involves cooperation from the patient, who has to front up daily for a rapid assessment and collection of the daily dose of hemineurin.

4. establish contacts with outside agencies, so inpatient stay is minimized and the benefits (to the patient) of referral are maximized; and

5. participate in the ongoing education of the medical and nursing staff of the hospital, to help ensure a rabonal approach to the care and management of the heavy drinker and drug user. This long-term project will minimize antagonism towards such patients.

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An example is the fear that was expressed by the nursing staff and senior medical administrators when we proposed having the methadone pick-up centre placed in casualty. It was the reasonable behaviour (not always exemplary) of ex-heroin users that changed the attitudes of the staff.

AREAS OF DIFFICULTY OR IMPORTANCE

1. Educational Thrust

In a hospital where the training of residents and registrars is ongoing, the medic within the unit needs to be always well read on issues surrounding alcohol and drugs, and to be seen as well-informed by his colleagues. This is a difficult task, especially where sub-specialities exist. For example, it is the gastroenterologist people instinctively seek advice from on alcoholic liver disease, and the endocrinologist when con- fronted with alcohol induced keto-acidosis.

The sub-speciality of "alcohologist" is new end highly suspect, and the abundant literature on the subject that disciplines the interested physician is generally unknown to other internists. He does not have the constant stimulus of college or sub-specialty meetings either, and the creation of the AMSADRP will help fill this gap.

Time to read is essential; so is the facility to isolate oneself from the hustle and bustle of a unit providing a service. There is no alternative but to recognize this problem, steadily grind away at it, and utilize the opportunities as they arise. They do come and, probably, the more able and well informed the incumbant is, the more rapidly they will come.

With this educational thrust there is the subtle question of ego and status: the need to belong, the need for approval and the value of feedback. These are personal issues, but they are real and must be recognized by the clinician, fellow staff and administrators. This raises the important point of:

2. Interpersonal Problems within the Unit

All staff members, like the physician must feel their roles are appreciated. In a unit of tour people it is essential to operate smoothly and with consideration to others. The job can be soul-destroying with the success rate low, the recidivist rate high, and numerous emotional scenes at the staff-client level. This thrust is most often directed at the social worker and, in the methadone program, towards the registered nurse. For any unit leader to be insensitive, or insufficiently perceptive at this level, is to invite discontent, though awareness of the possibil- ities alone does not guarantee its prevention. For example, the registered nurse does very little traditional nursing and her role has been difficult to define. She is therefore recognized by her nursing peers as different.

The role of the social worker has been easier to define, but not easy to implement. In Woden Valley Hospital, very few of the 21 social workers want to work in the DDU. The social worker who does end up working there feels in an off-beat area, one no one else wants. These points must be considered when choosing candidates for positions. For example, to place a young raw recruit, aged 21, in the situation of counselling a 29-year-old male, ex-heroin user who has just entered a methadone maintenance program, creates an impossible counselling situation and invites emotional rape (castration, if a male) of the fledgling social worker. Counselling clients on a methadone maintenance program is a difficult task and one that demands emotional maturity, high professional serf- esteem and regular support tor the counsellor. To date, we have been fortunate to have excellent, cooperative secretarial, social worker and nurse staff. The two units in the CTHC are different beth in operational philosophy and areas of respons- ibility.

ORGANIZATIONAL DIFFICULTIES

These are numerous, but two warrant brief discussion: 1. Should the DDU operate by providing an outpatient service

only? In WVH we have had good support from physicians who have agreed to admit those needing it. This has worked well. We have had good support from the gastro- enterology and psychiatric units. But, I could not say whether our unit has increased or decreased the work load on other units.

2. The second issue is the need for a detoxifying unit. The numbers alone do not warrant a special unit, but there is a need for a non-hospital, low-key detoxification unit to support all three Canberra hospitals and the Queanbeyan hospital. It could be staffed by a nurse during the day and a male nurse aide at night.

In summary, the following points are germane: • The hospital unit is an end unit. As Tom Stephens ° said

several years ago, it is like the terminal end of a spider naevus.

• Its capacity to deal with primary and secondary prevention is miniscule, but the staff should be encouraged to move into those areas.

• It should function as a full-time unit, and not on a sessional basis, with size varying according to need.

• It can function on an OPD basis and does not need direct access to beds.

• Areas of vexation are casualty, and its dealings with drunken persons, and the possible need for a separate detoxifying unit.

• There is constant conflict between the need to provide an educational stimulus to medical residents and nursing staff, and the need to provide a medical service.

* 1978 Autumn School Proceedings (Melbourne)

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