Author Topic: Involuntary/Coerced/Forced Reduction  (Read 8109 times)

Ken Stringer

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Re: Involuntary/Coerced/Forced Reduction
« Reply #15 on: October 05, 2011, 12:21:36 PM »
My two penn'orth...

The bottom line: OST is one of our best evidenced treatments. Anyone who can benefit from it and wants it should be able to have it as long as required.

But...

1. It's reasonable for providers to evaluate whether it is working well, still what the person wants, whether anything else is needed and so on, periodically. In fact this is pretty much a requirement of good care planning and not doing this is an abdication of their duty of care. One standard that might be good to clarify would be the frequency with which this happens. In particular, too often could be deemed harassment.

2. Care planning is fundamentally a client/patient centred activity and must primarily be about what the person whose care plan it is needs. If someone feels coerced to change, something has gone wrong. I'd like to see this stated in black and white.

3. There is a real resource issue that we can't ignore. The NHS doesn't give infinite numbers of hip replacements, fertility treatments, acute admissions for depression or anything else. All things being equal there is a quantity/quality trade off and beyond a certain point the quality will be so poor that safety and effectiveness are compromised. I'd like to see a clear Alliance statement about how we would best like this dilemma resolved where resources are inadequate.

At the moment, I think some people are being pressured off scripts to make way for new referrals and to address some of the poor quality treatment that can arise where keyworkers have excessive case loads. Arguably, there is a treatment contract once someone is receiving OST and itís a breach of that contract to vary it once it starts. I'm sure this is why a lot of people are pissed off. But would we prefer that new treatment episodes are not started if resources are insufficient? This the puts people outside of treatment at risk of course! Although in a sense this is "their problem" i.e. providers/commissioners, I think that not addressing this dilemma head on could make anything from the Alliance seem to lack credibility, because we would be ignoring a basic reality of the environment  in which these decisions and choices are made.

Personally, I feel more inclined towards a clearer defence of people's need for long term maintenance where that clearly exists and a clearer statement of the minimum quality standards for treatment including good access to relevant psychosocial support and (re)integration services (as per best evidence) and reasonable limits on workers' caseloads (necessary for client/patient safety and their well-being too). Only then will levels of under-resourcing become plainly visible. There's no easy answer, but I think it might be easier to campaign for more, better treatment if waiting lists start to grow than if we accept a gradual dilution of quality and dubious practices that cause people to feel coerced out of effective treatment.

4. We may need to recognize the limits to the evidence-base. Yes, the evidence generally supports OST, but it is not completely clear (in my reading of it anyway) on key issues such as its effectiveness when people are still drinking at high levels, injecting/using on top extensively, attending infrequently and so on. Of course, people should start by asking questions such as whether the dose is right etc, but it's not always just about dose and there are sometimes genuine, reasonable grounds to question whether treatment is safe, whether the person is benefiting and whether the treatment is actually effective in any given case. I honestly donít think these questions can easily be answered with reference to the evidence, because so often they hinge upon particular aspects of someoneís situation. Ultimately it is sometimes a clinical judgment, but this is where there is also scope for clinicians to manage people out if they are trying to hit performance targets. I donít know the answer to this whatsoever, but I think it is a problem we should acknowledge. 

Thatís more than enough from me I think!

Best
Neil

Thanks Neil, a very helpful post, if this response appears short my apologies, trains are not always conducive to good connections, if this ends up brief I will return to it later.

Firstly there are areas we clearly agree on, the evidence base for substitution prescribing is strong, it may not be exhaustive in terms of users that are drinking heavily etc as you point out, it is however evidenced as the most effective intervention we have, it continues to be NICE "gold standard", remains policy and best practice etc, objectively it cannot be argued with in terms of harm reduction, demand reduction, health improvement etc.  It would seem strange to me if a debate about this were even entered into it is a none issue.  The debate at the moment is about individuals being free to choose their own recovery route, to have control over decisions that effect their lives. For some this is a reduction or a drug free pathway, for others "stability equals recovery" (thanks for the quote B).  As an organization we support those seeking drug free options as we support those seeking maintenence, we stand for choice and self determination.  Unlike others seeking the national spotlight  we see all as having valuable and worthwhile lives.  Unlike the others we stand for all.

I certainly agree that there are resource issues but this is nothing new.  While there is much to celebrate from the past ten years, especially access to services being improved, there are also a number of areas where judgement has been poor, it is however not us that are paying for this it is those we purport to help, as a sector we seem to be protecting our own hallowed halls, businesses and skins without recognizing the sand that some of our estate is built upon.

As someone that argued for structural change before any spend of PTB, argued against targets set and structures that were being rolled out I cannot believe the need to rehearse these speeches again.  The whole system is fat, the product of lazy or incompetent commissioning, of duplication and waste, of paying over vast sums of money to buy pointless outputs, of the separation of treatment from the national drug strategy and of the reduction of the value of individual lives and ambitions to one of three colours, red amber or green and the bureaucracy to support this.

I agree with you in terms of where contracts can be seen to broken, problem is in many areas services were not fit to enter contracts in the terms you describe. We have some outstanding services and some good commissioners BUT..... During inspections i found many services had no effective case / care management system, reviews were poor or none existent, numbers were all, retention was everything regardless of client hope or ambition.  I still see highly qualified psychiatric staff being used to dip test while co-existent mental health problems go unaddressed.  We have duplication in terms of DIP, PPO and other acronyms signifying resources targeted at schemes that are not evidenced as reducing crime any more effectively than a walk in drug service. We have non random random tests (predictable does nothing for patient safety)and the need for people to take up counselling time with unqualified people we pay to provide this.  Access to structured sessions with qualified professionals is seen as too expensive to provide in some cases despite the evidence of effectiveness of this compared to ongoing chats over coffee with poor attempts at MI/MET between dip tests and TOPS forms.  Sorry for the rant, there are many areas of cost saving without the need to penalise the customer.  It is not the beyond the wit of many of us to design a treatment system which delivers safety, quality and outcomes for all comers, not just those deemed worthy.

I will follow this up more later, connection keeps dropping and this post is losing much of my intent in retyping.

Ken

usandthem

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Re: Involuntary/Coerced/Forced Reduction
« Reply #16 on: October 05, 2011, 02:27:29 PM »
Actually I didn't think about that part, Pogle strikes home the bare facts. Thanks Pogle. I can agree with Neils statement but I feel there is a balance shift from user care to commissioning. A major fault is happening here that user choice is being ignored so therefore it ceases to become about care. Clinicians under educated in their chosen fields are blinding users with their seminar and CRI conference pseudo scientific gobbledi goo statistics and data, instead of actually letting the medically trained professional known as the GP make the decision of when a patient is motivated, stable and ready for reductions and total abstinence.
The desire to alter your state of consciousness is universal

usandthem

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Re: Involuntary/Coerced/Forced Reduction
« Reply #17 on: October 05, 2011, 02:39:59 PM »
Ken Stringer. You are a great advocate for human fairness and equality. Your posts are so re-assuring to read. You are very rational and strike home what is real. Bravo!  ;)
The desire to alter your state of consciousness is universal

usandthem

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Re: Involuntary/Coerced/Forced Reduction
« Reply #18 on: October 05, 2011, 03:49:14 PM »
Ken, I don't think people on maintenance should never be asked about reduction, of course they should. All treatment options should be discussed with them,including abstinence. All people on OST scripts should have regular reviews (this is supposed to be "medical" treatment after all).

The issue is that when a service user is "challenged" about their "choices", if they wish to stay mainttained then that should be the end of the story unless the user brings it up again.

We are adults, we do not need to be "encouraged" off a medication that is helping us lead proserous and full lives, I know if I were to be forcibly reduced I would inevitably end up back on the street scoring.

The crux of the problem, I believe, is that too mainy keyworkers and DSP doctors see abstinence as the "true" goal of treatment and that methadone is only a stop gap measure or something those of us with "weak wills and morals" cling to.
Until we challenge those attitudes we are fighting a losing battle.

I do believe a service users charter would be of some use, only if it is to be used in the defence of Service Users, not to be used as another stick of punitive measures to beat us with.

I worry like mad about my keyworking appointments, as I know at every one there will be more pressure to start reducing again, and I feel like I can only put them off for so long.

The bottom line is, they do not see I have the choice to stay maintained long term, and will forcibly reduce me if they want to, even though this flies in the face of the NTA guidelines, so why would a Service Users' charter be any different?

Ken. Sapphire is right here. I think we need a circular to be sent to every dsp/MMTsurgery/CRIRecovery Service or its equivalent/Rehab controlled by the NTA NHS or Shared Care to be counter signed by all parties: Service User/GP/Keyworker/Service Manager/ and a copy given to all that a service user wants to take one of two choices and to be carefully read through and signed at the bottom in either the Recovery and after care .....................sign here or Remain in Maintenance until user is happy to have this reviewed .....................sign here  Wouldn't that make sense as it takes pressure off users and keyworkers can leave them alone until asked to implement recovery initiatives with the users blessings.
The desire to alter your state of consciousness is universal

froude

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Re: Involuntary/Coerced/Forced Reduction
« Reply #19 on: October 05, 2011, 06:37:54 PM »
Ken,Im with everyone on here as we all seem to be blowing from the same trumpet.What you said about highly qualified Mental Health Staff being used for dip tests,I have mental Health Issues, and in the past just gone in to my Key who is a Mental Health Worker and just given a urine test and my mental health was'nt even talked about.To be bluntly honest here i have been a Mental Health patient for a number of years, and when with the D.S.P team  iam with now im just getting my head sorted by my new Mental Health/Keyworker after god knows how many years,Thankyou and All the best Froude
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