Studies of psychiatric patients indicate a high rate of substance misuse among those diagnosed with schizophrenia (Reference Breakey, Goddell and LorenzBreakey et al, 1974; Reference Barbee, Clark and CrapanzanoBarbee et al, 1989; Reference Mueser, Yarnold and LevinsonMueser et al, 1990; Reference Mathers, Ghodse and CaanMathers et al, 1991). In this group comorbid substance misuse has been shown to be associated with a poorer outcome in terms of hospitalisation (Reference Haywood, Kravitz and GrossmanHaywood et al, 1995), violence (Reference Cuffel, Shumway and ChouljianCuffel et al, 1994), incarceration (Reference Abram and TeplinAbram & Teplin, 1991) and homelessness (Reference Drake, Mclaughlin and PepperDrake et al, 1991). In addition, research suggests that cannabis misuse results in an exacerbation of psychotic symptomatology, hostility and non-compliance with prescribed medication (Reference FreedFreed, 1975; Reference SaferSafer, 1987; Reference Cuffel, Heithoff and LawsonCuffel et al, 1993).
It is well recognised that illicit drug use is prevalent in psychiatric hospitals (Reference DeahlDeahl, 1991; Reference SandfordSandford, 1995), prisons (Reference WallaceWallace, 1993) and special hospitals (Fallon Inquiry, 1999). In secure psychiatric settings drug misuse is perceived as a significant risk factor for violent incidents, yet there has been little systematic study of the extent of the problem or the policies for dealing with illicit drug use among patients.
This study examined staff perceptions of the extent and impact of illicit drug use in a medium secure unit (MSU) for mentally disordered offenders.
Method
Experiment design
A questionnaire survey was conducted to collect data on staff perceptions of illicit drug use among current inpatients on the Edenfield Centre MSU during July 1998. The questionnaire was based on a similar survey conducted in a special hospital setting (Reference Mckeown and LieblingMcKeown & Liebling, 1995). All ward-based staff, including nurses, medical staff, psychologists, social workers and occupational therapists, were invited to participate. Subjects were asked to comment on the extent of illicit drug use among in-patients, the predominant drugs of misuse and the impact of illicit drug use on patients' mental state, ward atmosphere, staff—patient relationships and peer group interactions. In addition, subjects were asked to rate the likelihood of specific diagnostic groups being involved in drug use. Similar comments were invited about the likelihood that certain groups of patients (categorised on source of referral) misuse drugs. Unit policies on drug use and training needs for staff dealing with patients with comorbid substance misuse were explored.
Results
General characteristics of respondents
Sixty-two staff responded to the questionnaire (response rate 64%). The majority of returns were from nursing staff (n=48). The remainder were from junior medical staff (n=7), occupational therapists (n=5) and social workers (n=2). Of those not responding, senior nursing staff were overrepresented.
Extent and impact of drug use on the unit
The majority of staff (43, 69%) reported that over half of the patients on the unit had a comorbid diagnosis of drug misuse. The remainder estimated that between 5 and 40% had a history of drug use.
Thirty-seven (60%) staff were aware of in-patient illicit drug use. Sixty-one per cent were also aware of trafficking in prescribed drugs, particularly procyclidine. The most commonly reported illicit drugs coming into the unit were cannabis (92%) and amphetamines (54%). Seven subjects reported knowing that heroin, and three that cocaine, had been brought in.
Examination of staffs' perceptions of the impact of illicit drug use on the unit indicated that 51 (82%) staff felt that illicit drug use precipitated a relapse in patients with psychosis or an escalation in aggression. A further four (6%) staff felt that some patients appeared calmer or less disturbed on drugs such as cannabis. The majority of staff (47, 76%) reported that illicit drug use had a significant impact on peer group interactions, with 21 (34%) reporting increased bonding and alliance among drug misusers. Twenty-three (37%) staff, however, commented that drug use on the unit resulted in an escalation of bullying and intimidation. Twenty-eight (45%) felt that illicit drug use among in-patients had a profoundly negative impact on staff—patient relationships, with resultant increases in hostility from patients, reduced engagement in therapy and increased stress among staff.
Seven staff commented that some of the hostility from patients was generated because staff have to adopt a ‘policing’ role in the prevention of drug misuse on the unit. Examination of the impact of illicit drug use on ward atmosphere indicated that the majority of staff (51, 82%) believed that drug use resulted in an unpleasant atmosphere, with descriptions such as “strained”, “tense” or “disturbed”. Five (8%) staff, however, reported that drug use on the ward led to improvement in ward atmosphere because of the calming effects of drugs such as cannabis on some patients.
Staff perceptions of patient groups likely to misuse drugs
Staff were asked to rate the likelihood of patients from different referral sources being involved in in-patient drug use on a scale from one (very unlikely) to five (very likely). The mean ratings are shown in Table 1. Thirty-eight (61%) respondents rated patients transferred from a prison setting as being more likely to use drugs on the unit. Patients transferred from district general and special hospitals were perceived to be somewhat less likely to use drugs during their in-patient stay. On a similar scale, patients with a primary diagnosis of personality disorder were considered marginally more likely to be involved in drug use than those with a diagnosis of mental illness. The mean scores were 3.64 and 3.48, respectively, but were not significantly different.
Likelihood of and reasons for in-patient drug misuse
| Mean | s.d. | |
|---|---|---|
| Source of referral | ||
| Prison (sentenced) | 3.86 | 1.7 |
| Prison (remand) | 3.73 | 1.9 |
| Special hospital | 2.98 | 0.9 |
| District general hospital | 3.82 | 1.2 |
| Community | 3.22 | 1.4 |
| Reason for drug misuse | ||
| Personal enjoyment | 4.36 | 1.5 |
| Escapism | 4.12 | 1.7 |
| Peer-group pressure | 3.81 | 1.1 |
| Addiction | 3.67 | 0.9 |
| Self-medication | 2.60 | 1.8 |
| 1. Scale: 1=very unlikely, 5=very likely. |
Ninety-eight per cent of respondents believed that friends and relatives of patients were responsible for bringing drugs onto the unit. The remainder believed that patients smuggled them in following community leave.
Perceived reasons for drug misuse
Staff were asked to rate several predetermined reasons for illicit drug use among patients on a scale of likelihood (1=very unlikely, to 5=very likely). Personal enjoyment (51, 82%) was considered the most likely reason for drug use and the average ratings were high (Table 1). Escapism (45, 73%) was also considered a significant factor, while peer group pressures or self-medication were felt to be less common reasons for drug misuse. Additional reasons given by staff included boredom (17, 27%) and cultural identity (5, 8%).
Unit policy on illicit drugs
Twenty-four (39%) respondents reported that the unit had a policy of searching certain visitors' belongings. Eighteen (29%) indicted that the unit had a policy for conducting random room searches and 16 (26%) reported a policy for random urine drug screens. Forty-one (66%) staff felt that the police should be called if visitors were found with drugs and 33 (53%) suggested that those found carrying drugs should be banned from visiting.
For patients found in possession of illicit substances, 25 (40%) believed sanctions (e.g. loss of leave privileges) should be instituted. Nineteen (31%) suggested that the police should be notified, 15 (24%) reported that specialist drug education should be offered and 12 (19%) believed that counselling should be offered by the ward staff.
On the issue of facilities and therapies for patients involved in drug misuse, 22 (35%) respondents said there were no available facilities, 23 (37%) reported that keyworker basic training and support was the primary resource and 15 (24%) said that a referral to a drug unit could be made but rarely occurred because the latter service was primarily set up to treat opiate dependence. Training-needs analysis indicated that 30 (70%) members of staff had not received any training on drug misuse or drug-related issues in patients with mental disorder.
Comment
The overall response rate to the survey was higher than that in the Ashworth Hospital study (Reference Mckeown and LieblingMcKeown & Leibling, 1995). However, we found that the poorest response rate was from nursing staff, despite the relevance of the subject matter to their daily management of patients. Non-responders among nursing staff tended to be those in more senior managerial positions and may reflect a belief that illicit drug use at ward level is of less relevance to them than it is to the front-line staff. Given the finding that substantial numbers of front-line staff were not aware of, or were unclear about, the unit's policies on illicit drug use, it is clear that these protocols need to be reviewed.
This survey indicates that illicit and prescribed drug misuse is perceived as relatively common and that cannabis, amphetamines and procyclidine are the major drugs of misuse. The reported substance misuse rates and predominant drugs of misuse were similar to those reported in previous studies of patients with a primary diagnosis of schizophrenia (Reference Alterman, Erdlen and LaporteAlterman et al, 1980; Reference Galanter, Castaneda and FermanGalanter et al, 1988). Although staff appear to be aware of the affect of illicit substances on patients' psychopathology, they appear just as concerned about the impact of patients' drug-taking behaviour on staff—patient relationships, ward atmosphere and the risk of aggression. Similar concerns were apparent in the Ashworth Hospital study, and it seems that front-line staff in secure facilities are particularly worried about the culture that surrounds drug misuse and drug trafficking.
Staff's reports that patients transferred from prisons were more likely to misuse drugs than those transferred from other hospitals appear to reflect their belief that prisons have a greater problem with illicit drug use than secure psychiatric facilities. In the majority of cases staff believed that patients misused illicit drugs for personal enjoyment or escapism. This belief may explain why so many staff emphasise security-related strategies for dealing with illicit drug-taking behaviours in patients. The suggestion that the police should be involved in some cases also appears to support the notion that many staff see drug misuse in in-patient settings as a form of criminal activity rather than a comorbid psychiatric disorder.
We were surprised by the number of staff reporting that there were no facilities or resources available for the management of drug misuse, and the finding that primary nurses with little training were the sole providers of education and therapy for patients with dual diagnoses. The Edenfield Centre is situated on the same hospital site as the regional drug rehabilitation service, but it would seem that referrals to the drug service are largely reserved for opiate users. Given that a substantial number of staff feel they require training on drug-related issues, it would seem worthwhile to consider the introduction of a drug awareness and education programme to assist staff in the treatment of dual-diagnosis patients.
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