Recording of clinical information in a Scotland-wide drug deaths study.

The aim of this study was to analyse the nature and extent of data extracted from case files of deceased individuals in contact with services 6 months prior to drug deaths in Scotland during 2003. A cross-sectional descriptive analysis of 317 case notes of 237 individuals who had drug-related deaths was undertaken, using a data linkage process. All contacts made with services in the 6 months prior to death were identified. Information on clinical and social circumstances obtained from social care, specialist drug treatment, mental health, non-statutory services, the Scottish Prison Service and Criminal Records Office was collated. More than 70% (n = 237) were seen 6 months prior to their drug death. Sociodemographic details were reported much more frequently than medical problems, for example, ethnicity (49%), living accommodation (66%), education and income (52%) and dependent children (73%). Medical and psychiatric history was recorded in only 12%, blood-borne viral status in 17% and life events in 26%. This paucity of information was a feature of treatment plans and progress recorded. The 237 drug deaths were not a population unknown to services. Highly relevant data were missing. Improved training to promote in-depth recording and effective monitoring may result in better understanding and reduction of drug deaths.

The effects of a non-smoking policy on nursing staff smoking behaviour and attitudes in a psychiatric hospital.

The UK Department of Health required that by April 2001, all NHS bodies would have implemented a smoking policy. It has been suggested that the best demonstration a hospital can make of its commitment to health is to ban smoking on its premises. This paper reports on an evaluation of the effectiveness of a non-smoking policy in a newly opened NHS psychiatric hospital. Questionnaires were sent to all 156 nursing staff in a psychiatric hospital to assess the effectiveness of the policy in terms of staff smoking behaviour, attitudes to the restriction and compliance with the policy. Of the 156 questionnaires distributed, 92 (58%) were returned; smokers, former smokers and those who have never smoked were quite evenly represented at 34.78%, 34.78% and 30.43%, respectively. Of eight critical success factors for the policy, only one, staff not smoking in Trust public areas, had been achieved. A non-smoking policy was generally accepted as necessary by nursing staff working in a mental health setting. Staff felt that the policy was not effective in motivating smoking nurses to stop and that insufficient support was given to these nurses. The study highlights the importance of introducing staff support systems as an integral part of smoking policies and the role of counterintuitive behaviour in the effectiveness of smoking policy introduction in healthcare settings.

Substance misuse in the older population.

Substance misuse among the older population is largely overlooked and underreported. Many factors contribute to this, not least the fact that presentation may be atypical and hence easily missed by the medical practitioner. There may be many clues to its existence, provided the physician remains alert to these. Despite this it is quite comforting to know that once identified, the evidence to date suggests that older people may respond at least as well as younger people to treatment.

Comorbidity in young people: perspectives and challenges.

Trends in prevalence in substance misuse in young people in the UK are described: increased use over the last decade, the tendency to polydrug use, the narrowing of the gender gap. The complex issues relating to the description, definition and classification, and diagnosis of psychiatric comorbidity and substance misuse are outlined. The fact that there is no uniformly accepted definition of what constitutes 'dual diagnosis' or 'psychiatric comorbidity' in young people is highlighted: this variability impacts upon clinical assessment and study design. Despite these considerable drawbacks, a degree of consistency is beginning to emerge in the co-occurrence of some conditions, e.g. disruptive and suicidal behaviours. It is recognized that psychological distress and substance misuse are also associated with multiple social and physical complications. The rapid advances in treatment options are presented. At present the 'best practice' is implementation of what works for adults with addiction and young people with psychiatric disorder. This includes psychosocial interventions such as motivational enhancement techniques and cognitive behavioural treatment, as well as appropriate safe (usually), short-term use of a range of pharmacological agents. Very few comprehensive designated adolescent addiction services exist, while child and adolescent mental health services are under serious pressure. Thus the need for a longitudinal and multidisciplinary approach, with appropriate assessment instruments in young people, is required to further explore diagnostic classification which will classify the degrees and patterns of relationships between disorders. In this way it may be possible to build up a picture of the nature and extent of numerous complex, and sometimes overlapping, problems and needs in children and adolescents in a variety of settings: primary and secondary care, the criminal justice system and educational establishments. This might strengthen the development of innovative treatment services where novel interventions are tested as a priority.

Substance misuse amongst anaesthetists in the United Kingdom and Ireland. The results of a study commissioned by the Association of Anaesthetists of Great Britain and Ireland.

Three hundred and four departments of anaesthesia in UK and Ireland were sent questionnaires about alcohol and drug abuse in anaesthetists over the preceding 10-year period. Information was sought on the nature and extent of substance problems, their presentation and management. The survey achieved a high response rate of 71.7% and a total of 130 cases were reported, of whom 34.6% were consultants and 43.2% were trainees. Over 50% of respondents felt a lack of confidence in dealing with alcohol or drug misuse amongst colleagues. The results of this survey demonstrate that over one anaesthetist per month has presented with significant alcohol or drug misuse in the UK and Ireland over the last 10 years. It is important that those with management responsibilities for departments of anaesthesia are aware that such problems exist and are likely to impact on the professional ability and health of the affected individual. The Working Party on Substance Abuse at the Association of Anaesthetists has recently published guidance in the management of these problems. A case is made for increasing awareness in this sensitive subject to enable early recognition and treatment of an anaesthetist who is misusing alcohol and drugs since intervention can be effective.

Treatment interventions-looking towards the millennium.

This contribution is focused around treatment interventions employed when dealing with young substance misusers. By necessity, it draws on effective interventions which are applied to adult substance abusers. Where possible, research data on the effectiveness of interventions in young people are outlined and reviewed. The components of a comprehensive service are delineated. Suggestions for a framework for research are discussed, paying particular attention to some methodological difficulties in previous research.

A joint problem drinking clinic: the King's College and Maudsley hospitals initiative.

We describe the establishment of a joint alcohol misuse clinic, staffed by both a psychiatrist and a physician, in a London Teaching Hospital providing general as well as specialist medical services. The demographic and medicopsychiatric problems of the first 100 referrals (60% attendance rate) are described. The clinic provides an assessment and re-education role for most patients referred with alcohol misuse problems: the need for specialist alcohol treatment facilities, especially for in-patients, remains essential. In addition, the clinic provides a valuable training and research resource.

Alcohol misuse as challenge to medical education: a belated remedy.

Substance misuse contributes directly or indirectly to each of the 5 key targets outlined in the Health of the Nation strategy: coronary heart disease and stroke, cancers, mental illness, HIV/AIDS and accidents. More specifically, the risk factor targets include a 30% reduction in the prevalence of cigarette smoking to no more than 20% in both men and women by the year 2000; a 30% reduction in the proportion of men drinking more than 21 units of alcohol per week and women drinking more than 14 units per week to 18% and 7% respectively, and reduction in the percentage of drug misusers sharing equipment to no more than 5% in the year 2000. The Tomlinson report repeatedly underscores the problems of drug misuse, alcohol problems and mental illness in Inner London. Both these recent reports admit to a 'lack of trained professionals' (p17) and to 'ensuring that professionals ... are adequately and appropriately educated' (p97). Furthermore, Health of the Nation declares that 'Professional bodies in health and social work will continue to design training to promote the early identification of alcohol misuse, and appropriate referral skills' (p16).