Download Co-existing substance misuse with mental health issues

Co-existing substance misuse
with mental health issues
(CESMMHI) – proposed new
guidance
Luke Mitcheson, PHE Alcohol, Drugs and Tobacco Division
Contexts
Mental Health Intelligence Network – Coexisting Substance Misuse and Mental
health Issues ERG
Crisis Care Concordat (Norman Lamb) – recognition from government that MH
has been neglected
Our service users are significantly represented in crisis response / pathways
(Liaison and diversion in police cells, A&E )
DH 2002 guidelines “archived”
New bits of guidance (NICE, Orange)
Fragmentation in commissioning structures
Ongoing need to be addressed
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The Imperial College Co-morbidity Study (Weaver et al 2002)
To estimate prevalence of co-morbidity among current patients
of mental health and substance misuse services.
Drug Treatment Population
Mental Health Population
Psychotic disorder
7.9%
Problem drug use
30.9%
Personality disorder
37%
Drug dependence
16.7%
Severe depression
58%
Alcohol Misuse
25.5%
Minor depression
87%
Severe anxiety
41%
One or more disorder
74%
DH 2002 Guidelines
Focused on psychosis / severe MH
Key ideas:
Mainstreaming (MH lead)
Four quadrants: High / Low addiction severity and mental health need
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Current guidance: NICE
Adult Mental
Health
Alcohol
Drugs
Tobacco
• Psychosis with coexisting
substance misuse:
Assessment and
management in adults
and young people
(CG120) March 2011
• Alcohol-use disorders:
diagnosis,
assessment and
management of
harmful drinking and
alcohol dependence
(CG115) February
2011
• Drug misuse –
psychosocial
interventions (CG51)
July 2007
• Brief interventions and
referral for smoking
cessation (PH1) 2006
• Psychosis and
schizophrenia in adults:
treatment and
management (CG178)
February 2014
• Bipolar disorder: the
assessment and
management of bipolar
disorder in adults, children
and young people in
primary and secondary
care (CG185) Sept 2014
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• Methadone and
buprenorphine for the
management of opioid
dependence (TA 114)
January 2007
• Naltrexone for the
management of opioid
dependence (TA115)
January 2007
• Smoking cessation
services (PH10) 2008
• Tobacco: harmreduction approaches to
smoking (PH45) June
2013
• Smoking cessation in
secondary care: acute,
maternity and mental
health services (PH48)
Nov 2013
NICE guidance – CESMMHI?
Alcohol:
Tobacco:
•for co-morbid depression/anxiety treat the
alcohol use first
•smoking prevention/cessation in secure mental
health settings /secondary care (inc. mental
health)
•Tailor treatment goals (abstinence/moderation) to
take account of co-morbidity
Psychosis:
Drugs:
•ask about CESMMHI routinely
•Psychosocial guideline does not specifically
cover dual diagnoses
•Consider specialist advice from/joint working
relationships with specialist SM services
•Staff in mental health institutions should ask
routinely about drugs use
•Health professionals in SM services competent
to recognise psychosis
•No exclusion on the basis of diagnoses
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Drug Misuse and Dependence: UK guidelines on clinical
management (2007)
“…there is still a need for more collaborative planning, delivery and
accountability of services for people with comorbidity, including those with
mild-to-moderate mental ill-health, early traumatic experiences, and
personality traits and Disorders. Further concerns are of the lack of
specified core competencies, inadequate assessment and communication
between services, and the need for greater integrated care”
“The guiding principle should be to match the needs of the patient to the clinical
team and its competencies, minimise multiple referrals and movements
within multiple teams, and prevent exclusion from services (Raistrick et al.,
2006)”
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CESMMHI – guidance update
2002
Target audience - aimed at commissioners and providers
Local definition of CESMMHI, care pathways, interagency
protocols
Lead clinician/lead commissioner roles promoted
Implementation models:

SM/AMH develop agreed care pathways supported by
liaison worker roles

Each sector to provide training input/support to the other
2015
Definition/scope - ‘co-existing’ to include Tobacco and CMI not just
severe MHI
Landscape - commissioning landscape has changed
Terminology – ‘dual diagnosis’ replaced with ‘co-existing substance
misuse and mental health issues’
Increased focus on staff competency - mental health services should
be competent to respond to presenting substance misuse and vice
versa
Move away from exclusion by diagnosis and focus on competency to
treat – individual should still be offered support for other issues
and/or to access appropriate care elsewhere
Increased focus on responses to crisis care
‘Collaborative care’?
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Implications for Addictions providers
Involvement at local level in strategic partnership with MH (Commissioner led)
Service governance structures that can enable MH needs to be identified and
appropriately care-planned
Consultation, advice and training to MH providers on substance misuse
Staff competent:
To assess and identify mental health problems
To know when to refer to MH in line with NICE guidance
To monitor MH on an ongoing basis
To deliver psychological therapies for common mental health problems
where addiction severity would be a barrier to accessing IAPT services
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