Working with people recovering from Working with people recovering from Substance MisuseSubstance Misuse

A workshop presentation byA workshop presentation by

Laura Walker Laura Walker ofof Bury Drug and Alcohol Service Bury Drug and Alcohol Service andand

Michael Dean Michael Dean ofof Bury Employment Support and Bury Employment Support and TrainingTraining

Laura WalkerLaura Walker

Detox nurse and recovery worker with Bury Detox nurse and recovery worker with Bury Drug and Alcohol ServiceDrug and Alcohol Service

1.Health & Welfare of Individuals 70s/80s1.Health & Welfare of Individuals 70s/80s

2. Public Health & HIV prevention 80s/90s2. Public Health & HIV prevention 80s/90s

3. Crime Reduction & Community Safety 90s/2000s3. Crime Reduction & Community Safety 90s/2000s

Tackling drugs to build a better Britain’ drug strategy ‘98 Tackling drugs to build a better Britain’ drug strategy ‘98

▪ Double numbers in treatment ▪ Double numbers in treatment

▪ No’s in treatment ▪ No’s in treatment

▪ Led to the acceptance of the harm reduction model ▪ Led to the acceptance of the harm reduction model keeping people in treatment, keeping people well and alive in maintenance px. keeping people in treatment, keeping people well and alive in maintenance px.

Setting the SceneSetting the SceneA look back at Drug StrategyA look back at Drug Strategy

4 - Ten years on, the new drug strategy for 2008-18 has seen a shift of focus 4 - Ten years on, the new drug strategy for 2008-18 has seen a shift of focus on to moving people on in treatment and reintegrationon to moving people on in treatment and reintegration

The four strands of work within the strategy are: 

▪ protecting communities through tackling drug supply, drug-related crime and anti-social behaviour

▪ preventing harm to children, young people and families affected by drug misuse

▪ delivering new approaches to drug treatment and social re-integration

▪ public information campaigns, communications and community engagement

Key features of the strategy

Individuals integrating into local communities

Providing meaningful support and opportunities

Interagency involvement and working together

Training and employment opportunities are a key part of this reintegration80%+ North West Heroin Addicts workless (NTA presentation)

Integrating people with substance misuse problems into the community

Treatment optionsTreatment options

Models of Care (2002 & 2006 NTA)Models of Care (2002 & 2006 NTA)

▪ Outlined the need for good quality, effective drug treatment.▪ Outlined the need for good quality, effective drug treatment.

▪ Attempted to reduce the postcode lottery of treatment▪ Attempted to reduce the postcode lottery of treatment

▪ Gave guidance on commissioning good quality care based on a tiered ▪ Gave guidance on commissioning good quality care based on a tiered frameworkframework

Treatment Treatment

Tier 1 – Non specialist services screening/referralTier 1 – Non specialist services screening/referral▪ GP’s▪ GP’s▪ A&E▪ A&E▪ Job centre services ▪ Job centre services

Tier 2 – Harm reduction servicesTier 2 – Harm reduction services▪ Needle exchange▪ Needle exchange▪ Blood borne virus screening and referral▪ Blood borne virus screening and referral▪ Wound care▪ Wound care▪ Confidential service which can promote entry into treatment▪ Confidential service which can promote entry into treatment

Treatment cont..Treatment cont..

Tier 3 – Care planned Treatment

▪ 1:1 sessions – psychosocial interventions

▪ Group work – leisure activities 'normalise lives'

▪ Community Prescribing (Buprenorphine, Methadone, maintenance, reduction to include psychosocial interventions)

▪ Community detoxification at home with support

Abstinence/Recovery based services/Naltrexone prescribing

▪ Tier 4 – Inpatient detoxification and Rehabilitation

Clients who misuse substances often have very complex needs Clients who misuse substances often have very complex needs

Good Assessment and Care planning is needed – 4 domainsGood Assessment and Care planning is needed – 4 domains

▪ ▪ Drug & alcohol useDrug & alcohol use

▪ ▪ Physical and psychological healthPhysical and psychological health

▪▪ Offending behaviourOffending behaviour

Social factors including employment and educational needsSocial factors including employment and educational needs

Assessment and Care planningAssessment and Care planning

Recovery – The hot topicRecovery – The hot topic

Traditionally talked about at the end of a treatment journeyTraditionally talked about at the end of a treatment journey

Now exit strategies should be planned at the startNow exit strategies should be planned at the start

Recovery doesn’t have to mean abstinence, but abstinence is a real Recovery doesn’t have to mean abstinence, but abstinence is a real offer.offer.

Working group consensus definitionWorking group consensus definition

‘‘The process of recovery is characterised by voluntary sustained The process of recovery is characterised by voluntary sustained control over a substance use which maximises health and well-being control over a substance use which maximises health and well-being and participation in the rights, roles and responsibilities of society’and participation in the rights, roles and responsibilities of society’ prof prof J. Strang et al.J. Strang et al.

Recovery in practice - Recovery in practice - A local A local perspectiveperspective

Service users often cite it is the normal things they enjoy the most, the ability to have a job, earn money and live normally, but a large amount of support is often necessary.

▪ Needs to be local and visible – mixing abstinence based services

▪ Can be self led – peer to peer (SMART, NA)

▪ Needs to embrace ex users and volunteers in to our treatment systems; volunteers are supported in Bury by the Trust and also by Bury EST

▪ Joint working with Bury EST team work/other agencies

ROIS: Recovery Oriented Integrated SystemROIS: Recovery Oriented Integrated System

3

Mutual Aid

Structured Day Care

HarmReduction

Services,NX

GPPrimary

CarePsychoSocial

Tier 4IPDetox, Res Rehab

T3 - Community Drug ServicesSubstitute Medication Assisted

Treatment (e.g. MMT)

Single Point of Assessment & Access

Prisons(IDTS)

Housing

Employment

Sounds Ideal, but what about the realities, Sounds Ideal, but what about the realities, practicalities and barrierspracticalities and barriers

▪ Intergenerational drug use

▪ Housing and other difficulties

▪ Criminal records

▪ Appointments with agencies, DAS, social services, probation, Hepatitis

▪ Chemist attendance daily, supervised consumption

What we can doWhat we can do

▪ Adopt non judgemental style

▪ Reassurance around benefits

▪ Motivational interviewing – moving people on

▪ Be flexible in chaos

▪ Set short term achievable goals

▪ Mapping

▪ Remind people about appointments

▪ Ask local substance misuse teams to provide training

▪ Run employment support sessions in local substance misuse services

▪ Joint working

Bury Bury ESTEST

Mick Dean – Supported Employment PractitionerMick Dean – Supported Employment Practitioner

Currently working in partnership with Bury DAS on the ‘Workwise’ Currently working in partnership with Bury DAS on the ‘Workwise’ project. A scheme aimed at rehabilitating people recovering from project. A scheme aimed at rehabilitating people recovering from substance misuse into employment, education and training.substance misuse into employment, education and training.

Tackling Drugs Changing Lives – Government Drug Strategy 2008-2018 Tackling Drugs Changing Lives – Government Drug Strategy 2008-2018

Key Strands

The four strands of work within the strategy are: 

protecting communities through tackling drug supply, drug-related crime and anti-social behaviour

preventing harm to children, young people and families affected by drug misuse

delivering new approaches to drug treatment and social re-integration

public information campaigns, communications and community engagement

Key policies - these include:

Developing a package of support to help people in drug treatment to complete treatment and to re-establish their lives, including ensuring local arrangements are in place to refer people from Jobcentres to sources of housing advice and advocacy and appropriate treatment

Using opportunities presented by the benefits system to support people in re-integrating into society and gaining employment, with a commitment to examine further how claimants can be encouraged to engage with treatment and other services Piloting new approaches which allow a more flexible and effective use of resources, including individual budgets to meet treatment and wider support needs

Substance dependence is a complex disorder with biological mechanisms Substance dependence is a complex disorder with biological mechanisms affecting the brain and its capacity to control substance use. It is not only affecting the brain and its capacity to control substance use. It is not only

determined by biological and genetic factors, but psychological, social, cultural determined by biological and genetic factors, but psychological, social, cultural and environmental factors as well. Currently, there are no means of identifying and environmental factors as well. Currently, there are no means of identifying

those who will become dependent – either before or after they start using drugs. those who will become dependent – either before or after they start using drugs. Substance dependence is not a failure of will or of strength of character but a Substance dependence is not a failure of will or of strength of character but a medical disorder that could affect any human being. Dependence is a chronic medical disorder that could affect any human being. Dependence is a chronic

and relapsing disorder, often co-occurring with other physical and mental and relapsing disorder, often co-occurring with other physical and mental conditions.conditions.

Source: World Health Organisation – 2004 “Neuroscience of psychoactive substance use and dependence”

What is a substance dependencyWorld Health Organisation Definition

The complex nature of drug The complex nature of drug dependence and the associated dependence and the associated multiple needs of individuals with this multiple needs of individuals with this condition suggests that programmes condition suggests that programmes aimed at getting people recovering aimed at getting people recovering from substance misuse into from substance misuse into employment will need to address employment will need to address multiple issues, provide support over multiple issues, provide support over a long period and be structured to a long period and be structured to deal with relapses, as part of a deal with relapses, as part of a “rehabilitation package”“rehabilitation package”

Source: UK Drug Policy Commission 2008Source: UK Drug Policy Commission 2008

Supported employment, or the SE model, may be best placed toward helping people who Supported employment, or the SE model, may be best placed toward helping people who are committed to working towards recovery and rehabilitation. Namely individuals who are committed to working towards recovery and rehabilitation. Namely individuals who voluntarily engage with drug and alcohol services in order to begin the process of recovery. voluntarily engage with drug and alcohol services in order to begin the process of recovery.

The process of learning how to positively re-structure time is an essential component of The process of learning how to positively re-structure time is an essential component of rehabilitation – life on drugs is dramatically different than life before and after drug use.rehabilitation – life on drugs is dramatically different than life before and after drug use.

In order for individuals to successfully reintegrate into mainstream life, many will need to In order for individuals to successfully reintegrate into mainstream life, many will need to learn new skills (soft, life, special skills) through structured and meaningful activities .learn new skills (soft, life, special skills) through structured and meaningful activities .

Source: UKDPC Working towards recovery: Getting problem drug users into jobs – December 2008

The Employment Continuum: stages that require support, mentoring and training

The Employment Continuum – First Things First

• The employment continuum follows the principles of Mazlow’s Hierarchy of Need. Domestic stability and a sense of well-being need to be established first otherwise employment cannot realistically be sustained.

• Research commissioned from the University of Manchester identified a range of ‘primary needs’ for those who are furthest from the labour market.

• These are needs that must be addressed in the early stages of treatment and rehabilitation to allow for sustainable recovery and employment.

• Failure to address these other problems will profoundly undermine attempts by all those involved to secure improved employment outcomes.

• Employers are, understandably, unlikely to be interested in employing people who are not ready for work.

• There are also dangers (including relapse) associated with applying pressure on people to take part in employment programmes for which they are not ready

Source: UKDPC: Working towards recovery: Getting problem drug users into work. Dec 2008

From drug use to employabilityFrom drug use to employability

• This journey is going to be unique for each individual dependent upon their starting point, their skills, their self esteem and their self confidence

• Other organisations will invariably be involved with the client therefore co-ordination between organisations is crucial to develop a support network for the client

• The transition into ‘normal life’ activities may be considerable therefore progression in small steps – help overcome barriers one at a time based upon order of priority (client focussed development planning).

Common barriers for recovering substance misuseCommon barriers for recovering substance misuse

• Amplified low self-esteem and self-confidence – a considerable barrier in itself – often based on the perception that society sees them as ‘low life’

• Many will have led non-conventional and chaotic lives based around getting and using drugs

• Many will have a criminal record as a result of obtaining drugs or cash for drugs

• Many will have poor soft skills – time keeping, keeping to appointments

• Maintenance: will prioritise around obtaining ‘scripts’ – prescriptions

• Health issues such as Hep C, HIV, problems arising from heavy needle use

• May not have a social or familial network to provide additional support – some move away to break free of their fellow drug takers (however - some have supportive families)

• May distrust professionals initially, especially if the perception is that they will be forced into doing something they don’t want.

• May be too ashamed to let you know if they have suffered a relapse

• May suddenly disengage – not communicate any difficulties/problems

Good PracticeGood Practice• Avoid the use of appointment letters whenever possible – they may go

unopened and therefore unread – phone or make contact with DAS Keyworker even during a keyworker-meeting.

• Reduce the fear factors - From the outset make it clear that clients will not be expected to take a job immediately unless that is their desired choice.

• From the outset make it clear that a clients’ own aspirations will always be considered first.

• Make provision for educational options – many will favour or need education or training courses before desired employment can be obtained.

• Where appropriate treat educational establishments as if they were a workplace – clients may be equally anxious about attending college as a place of work and will need support.

Good PracticeGood Practice

• Where appropriate identify appropriate mentors within colleges

• Act as mentor throughout a college course – critical to encourage clients to feed back any difficulties they may encounter.

• Acquire Police Access Checks for individuals who cannot remember the detail of their past criminal history (essential for filling out CRB checks).

• Always be mindful of any treatment (Hep C, for example) a client is undergoing as that may impact on an individuals ability to focus.

• A judgmental attitude will destroy any client/practitioner relationship

Links / Resources / BibliographyLinks / Resources / BibliographyUK DRUG POLICY COMMISSION• http://www.ukdpc.org.uk/resources/Working_Towards_Recovery.pdf• http://www.ukdpc.org.uk/resources/Response_to_NOWO_Oct08.pdf Response to Govt (DWP)

Green Paper ‘No one written off’

NATIONAL TREATMENT AGENCY (NTA) • http://www.nta.nhs.uk/

DEPARTMENT OF HEALTH• http://www.dh.gov.uk/en/index.htm

HOME OFFICE – TACKLING DRUGS CHANGING LIVES• http://drugs.homeoffice.gov.uk/• http://drugs.homeoffice.gov.uk/drug-strategy/

TALK TO FRANK – FIND OUT ABOUT DIFFERENT DRUGS AND THEIR EFFECTS• http://www.talktofrank.com/

NEUROSCIENCE OF PSYCHOACTIVE SUBSTANCE USE AND DEPENDENCE • http://www.who.int/substance_abuse/publications/en/Neuroscience.pdf