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Combined Psychosis and Substance Use COMPASS Programme Birmingham and Solihull NHS Mental Health Trust

The COMPASS Programme Birmingham 2007. 2. "E-post-fisketuren" til Birmingham. Douglas Turkington (i Norge sept 2006 om "CBT for psychosis" som spurteDavid Kingdon som foresloChristine Barrowclough som foresloAlex Copello and Hermine L Graham som ba oss kontakteDerek Tobin - som med sitt team

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Combined Psychosis and Substance Use COMPASS Programme Birmingham and Solihull NHS Mental Health Trust

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    1. The COMPASS Programme Birmingham 2007 1 Combined Psychosis and Substance Use (COMPASS) Programme Birmingham and Solihull NHS Mental Health Trust Besřk i regi av RKDD november 2007 John Arrowsmith Wilhelmsen

    2. The COMPASS Programme Birmingham 2007 2 ”E-post-fisketuren” til Birmingham Douglas Turkington (i Norge sept 2006 om ”CBT for psychosis” som spurte David Kingdon som foreslo Christine Barrowclough som foreslo Alex Copello and Hermine L Graham som ba oss kontakte Derek Tobin - som med sitt team ble vĺrt hyggelige vertskap – i 2 dager.

    3. The COMPASS Programme Birmingham 2007 3 Visitors for Norway 6th & 7th nov 2007 Based at 12-13 Greenfield Crescent Information from Derek Tobin (and team) Q & A with a) Hermine L Graham and Alex Copello b) Two Assertive Outreach teams Visit to/from two Community Drug teams

    4. The COMPASS Programme Birmingham 2007 4 DH (2002) Mental Health Policy Implementation Guide Dual Diagnosis Good Practice Guide The COMPASS programme highlighted as a model of good practice.

    5. The COMPASS Programme Birmingham 2007 5 Dual Diagnosis Good Practice Guide forts.. Substance misuse is usual rather than exceptional amongst people with severe mental health problems and the relationship between the two is complex. Individuals with these dual problems deserve high quality, patient focused and integrated care. This should be delivered within mental health services. This policy is referred to as ”mainstreaming”

    6. The COMPASS Programme Birmingham 2007 6 Birmingham and Solihull NHS Mental Health Trust Catchment area multicultural and inner city with population approx 1,2 mill ”Mainstream” within the Trust are functionalised tailored community mental health teams – such as assertive outreach (6),early intervention (3), home treatment (5), rehab & recovery (4), community drug (3), team for homeless, inpatient units, forensic services primary community liason (10) etc…

    7. The COMPASS Programme Birmingham 2007 7 The COMPASS Programme evolved since 1997 (1998 i DH 2002) as a specialist multi-disciplinary team include(d) a service director/clinical psychologist, research psychologist, three senior community psyciatric nurses, a senior occupational therapist and sessional input from a consultant psychiatrist. aimed to train and support existing ”mainstream” mental health and substance misuse services still ”evolving”

    8. The COMPASS Programme Birmingham 2007 8 The ”COMPASS” BOOK ”Cognitive-Behavioural Integrated Treatment (C-BIT)” Hermine L Graham (2004) with Alex Copello, Max J Birchwood, Kim T Mueser, Jim Orford, Dermot McGovern, Emma Tkinson, Jenny Maslin, Mike Preece, Derek Tobin and George Georgiou

    9. The COMPASS Programme Birmingham 2007 9 The ”COMPASS” BOOK cont A type of DIY book – operationializing therapeutic interventions in a structured yet flexible way to collaboratly tackle problematic drug/alkohol use amongst clients with severe mental health problems Overall objective om C-BIT is to negotiate and facilitate – with clients – som positive change in their problematic drug/alhol use ”Harm reduction” – reduction in amount/type/the way the substance is taken – are alle ”positive changes” – as well as abstinence

    10. The COMPASS Programme Birmingham 2007 10 The ”COMPASS” BOOK cont C-BIT consists of core components an assessment phase Screening and Assessment four treatment phases 1. Engagement & Building Motivation to Change; 2. Negotiating some Behaviour Change; 3. Early Relapse Prevention 4. Relapse Prevention & Relapse Management and two additional treatment components Skills Building (6 topics) Working with Families & Social Network Members

    11. The COMPASS Programme Birmingham 2007 11 Eksempler fra opplćringsprogrammet: Taken from Compass CD-rom Consists of 15 ”modules” for training/skilling staff Content also based on a survey amongst staff indicating where knowledge and skills were needed and wanted Implementation requires positive attitudes, dedicated leadership and follow-up supervision.

    12. The COMPASS Programme Birmingham 2007 12 Exercise: Why Use? Why do I (did I) smoke cigarettes; drink caffeinated drinks e.g. coffee, tea, cola; drink alcohol? Make a list of the reasons why, the benefits, and if there are any, some of the less good aspects of these habits. Why do people with mental health problems use drugs and alcohol? Make a list of the reasons that you are aware of from what service users have told you, or assumptions that you have made.

    13. The COMPASS Programme Birmingham 2007 13 Reasons for use To feel euphoric or feel nothing To feel more confident To work longer hours or enhance performance To belong to a social group (peer pressure) To kill time (alleviate boredom) To alleviate physical pain and other health problems Because it is a habit To satisfy cravings and avoid withdrawal symptoms For weight loss To experience an altered state of consciousness To unwind after a stressful day

    14. The COMPASS Programme Birmingham 2007 14 Cocaine and Crack Cocaine Stimulant drugs Legality- class A drugs What do they look like: cocaine is a white crystalline powder, and crack is white or off-white crystalline rocks How taken: Cocaine may be taken orally, snorted, inhaled, or injected. Crack: inhaled from a pipe, but sometimes injected. Effects: Cocaine, in both forms, increases heart rate, breathing, blood pressure, thoughts and activity levels. It also lifts mood and gives a sense of energy and wellbeing. Signs of use: dilated pupils, dry mouth, elevated body temperature, teeth grinding, agitation, restlessness, excitability, pressure of speech, flight of ideas, weight loss (appetite suppressant). Risks: paranoia, confusion, and disorganized patterns of behaviour. The “come down” period causes fatigue, and depressed mood. Heart attacks, hgh blood pressure, stroke, and kidney damage

    15. The COMPASS Programme Birmingham 2007 15 Opiates Derived from the opium poppy. They include heroin, morphine, methadone and codeine. Central nervous system depressants Legality: these are class A drugs What they look like: heroin is a pale brown powder; also available in pharmaceutically manufactured form such as tablets, green or blue syrup (methadone) and glass ampoules (for injection) How used: mainly smoked or injected, some opiates are available in tablet and suppository form. Signs of use: pallor, pinprick pupils “pinned”, sedation/drowsiness (“gouching out”), signs of injecting on body Effects: people feel emotionally numb, warm and drowsy, with an initial intense rush, especially if injected intravenously. Withdrawals: gooseflesh, shivering, profuse sweating, feeling feverish, aching limbs, yawning, runny eyes, runny nose, gastrointestinal disturbances such as stomach cramps, nausea, vomiting and diarrhoea. Risks: overdose, injecting related problems, BBVs, accidents

    16. The COMPASS Programme Birmingham 2007 16 Benzodiazepines and Substance Use Benzodiazepines (tranquillisers) such as diazepam are highly addictive and very difficult to withdraw from. High doses of benzo’s act like alcohol leading to paranoia, disinhibition and aggression. They interact with other depressants (alcohol, heroin etc) increasing sedative effect and toxicity If mixed with depressants, can lead to accidental overdose and death. Have a high “street value”. Prescription of benzo’s should be for short term (2 weeks) treatment for anxiety only.

    17. The COMPASS Programme Birmingham 2007 17 Maximum detection times for drugs in urine Amphetamine- 2-3 days Ecstasy- 30-48 hours Cannabis: Single use- 3 days Moderate use- 4 days Heavy use- 10 days Chronic heavy use- 36 days Methamphetamine-48 hours Cocaine- 6-8 hours Methadone- 7-9 days Codeine- 24 hours Heroin- 1-2 days

    18. The COMPASS Programme Birmingham 2007 18 Exercise: Confidentiality: Take 10 minutes to consider: What are the boundaries of confidentiality within your role around the disclosure of substance use? At what point would you breach confidentiality, and how would this be communicated to the service user?

    19. The COMPASS Programme Birmingham 2007 19 Confidentiality Doesn’t mean secret! Be up front about who gets access to information and why. Illegal activities may have to be reported to the police (dealing drugs, threats of violence, serious crimes) Child protection issues will need to be reported. Respect peoples’ right to privacy within limits. Carers want and need information, and this should be shared only with full consent of the service user unless there are safety/legal issues. Carers may have important information for the care of the person Balance needs of individual against safety of others Fully explain why confidentiality may be breached. May have to re-engage person at a later stage.

    20. The COMPASS Programme Birmingham 2007 20 Cognitive Behavioural Assessment Gain an understanding about what triggers and maintains their substance use (and other problems) Generate problem statements that can be turned into goals. Assess what happens in 6 domains/areas: Cognitive (what are you thinking? What goes through your mind when…) by this we are trying to elicit the thought processes and decision-making. Physical (what sensations do you notice in your body?) Affective (how do you feel when…..) Behavioural (what do you do as a result of…) Interpersonal (who are you with and how do they affect you), Situational (where are you? in what setting does this seem to happen?)

    21. The COMPASS Programme Birmingham 2007 21 An example What is the area to be focused on: alcohol use When-most evenings, who with-friends, where-pub, why-because I feel miserable and it cheers me up Domains: affect-it makes me feel happy initially, then I get angry, physiological-I feel relaxed, interpersonal-I am more sociable but I do have more rows when I am drunk. Psychological- feel paranoid by end of evening. Frequency-daily, intensity- 5 pints, duration- 7pm till 11pm, onset-mate calls for me at 6.30 in the hostel

    22. The COMPASS Programme Birmingham 2007 22 Problem statement John spends the day alone in the hostel. He looks forward to going to the pub with his mates in the evening. He drinks an average of 5 pints (5%) lager. Initially he feels happy, relaxed and sociable, but as he drinks more he starts to think that other people in the pub are talking and laughing at him. Because he is drunk, he ends up shouting at people and then is asked to leave.

    23. The COMPASS Programme Birmingham 2007 23 Possible areas of intervention Improve daily activities Introduce non-drinking social activities Explore Johns feelings of paranoia Assess further his mental state Psycho-education re alcohol-effects on psychological and physical health Assess for alcohol dependence Assess motivation to reduce alcohol

    24. The COMPASS Programme Birmingham 2007 24 Working with Beliefs Identify beliefs about substances Ask person to consider the evidence for and against the beliefs (e.g. does cannabis always calm you down? Assist the person to generate some alternative beliefs or thoughts that may be more helpful (e.g. I want to smoke cannabis as I am stressed but it just makes things worse in the long run) This in turn may help change the consequences (decides not to smoke cannabis)

    25. The COMPASS Programme Birmingham 2007 25 Harm Minimisation This is an approach to treatment that advocates interventions that seek to reduce or minimise the adverse health consequences of substance use. It acknowledges that not everyone who comes for help wants to stop using substances completely at that point in time. The main aim is to prevent harm as a result of disease, overdose, or drug-related deaths. This also incorporates the mental health risks associated with some drugs and alcohol consumption

    26. The COMPASS Programme Birmingham 2007 26 Harm Minimisation Interventions Needle exchanges. Advice about safer injecting and safer drug use. Advice about the prevention of infection with blood-borne viruses (HIV, hepatitis B and C). Testing, advice, counselling and treatments for blood-borne viruses. Advice about preventing overdose and drug-related deaths. Education about the effects of illicit substances on mental health, and interactions with prescribed medications.

    27. The COMPASS Programme Birmingham 2007 27 Physical Health Issues for Dual Diagnosis People with mental health and substance use generally suffer from poor physical health. People with schizophrenia are at risk of developing type II diabetes (possibly in connection with obesity), heart problems (extended Q wave interval), smoking related illnesses such as cancer. People who use substances: Cardiac problems, Circulatory problems, Malnutrition Poor dental hygiene Injecting drugs then this comes with an array of associated problems. Heavy alcohol consumption is associated with a significant number of health problems.

    28. The COMPASS Programme Birmingham 2007 28 Injecting and Sexual Health Assessment All service users with dual diagnosis should be asked about injecting behaviour- they may have tried it in the past Give a clear rationale questions about injecting and sexual behaviour and advise that they may feel embarrassed The worker should be in a position to answer questions, offer reassurance and be able to refer to appropriate services that can offer more detailed assessment and interventions. Requires a basic knowledge of: blood borne viruses and testing facilities sexual health clinics and advisors needle exchanges in the community, safer injecting practices and safer sex. Therefore it is important to find out about local services, and have literature available. Information should be presented in a rational and balanced way.

    29. The COMPASS Programme Birmingham 2007 29 Examples of Key Questions Have you ever injected? (People with dual diagnosis are less frequent injectors but even once before warrants further exploration as to how safe their practice was) If so, where did you obtain your injecting equipment? (This is to check if sterile equipment was used, or whether equipment that had been used before) Where do (did) you inject? May I see where you inject (check for abscesses, ulcers, and general quality of the injecting area) What is your current form of contraception? (Do they use condoms? If not have a discussion about the importance of using condoms to prevent transmission of sexually transmitted diseases and where condoms can be obtained) Have you ever had any sexually transmitted diseases? (The risk of HIV is higher in those who have had STD’s. It’s also an indicator of unsafe sex) What is your appetite like in the last 4 weeks? What is your typical diet like? Have you any health concerns at the moment? When was the last time you saw your G.P. (check if they have a G.P.!)-

    30. The COMPASS Programme Birmingham 2007 30 How people change They undergo a series of cognitive and behavioural processes Involves belief in own ability to change (self-efficacy) Self-esteem- I am worth changing for Own rationale for change (the benefits outweigh the cost or loss)

    31. The COMPASS Programme Birmingham 2007 31 Cycle of Change (Prochaska and Diclemente, 1996)

    32. The COMPASS Programme Birmingham 2007 32

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