National
Assembly for Wales / Cynulliad Cenedlaethol
Cymru
Health
and Social Care Committee /
Y Pwyllgor Iechyd a Gofal Cymdeithasol
Inquiry into alcohol and substance misuse / Ymchwiliad i gamddefnyddio alcohol a sylweddau
Evidence from Dr Jake Hard, Clinician – ASM(Q) 18 / Tystiolaeth gan Dr Jake Hard, Clinigydd – ASM(Q) 18
Inquiry into alcohol and substance misuse
Survey Consultation Response
Organisation/Respondent: Dr. Jake Hard
I have several current roles which provide me with a variety of perspectives on people who misuse drugs and/or alcohol.
Clinical Roles:
1. Prison GP - HMP Swansea
2. GP with Special Interest in Substance Misuse - ABMU Community Drug and Alcohol Team
Non-Clinical Roles:
1. Chair of the RCGP Wales Secure Environments Network
2. I provide advice to the Parliamentary and Health Service Ombudsman
Questionnaire
01. Which client group(s) do you work with? (For example, under 18s, older persons, homeless, or female only)
In my Prison GP role, I deal solely with male patients and over 18 in age. The prison setting has a very high prevalence of substance/alcohol misusers who require assessment for treatment on admission for syndromes of acute withdrawal. This often ‘polysubstance’ in that people will often report significant levels of use of illicit opiates (Heroin, Subutex, methadone), illicit valium (MSJs) as well alcohol. This makes physical assessment challenging given that there are a number of conflicting issues to consider – 1. Withdrawal syndromes and their treatments will overlap in time and clinical features 2. The over riding principle not to do any harm 3. Patients’ expectations (previous treatment etc.)
It is also worth noting that there is also a level of substance misuse amongst prisoners who have been incarcerated for some time and the drugs being used tend to be different to those used in the community. For the last few years we have been seeing a large amount of illicit subutex used on the prison wings, but more recently the rumour is that ‘legal’ highs are becoming more common although we have no evidence for the latter as we do not test for them,
Some of my patients will be effectively homeless on release from prison.
In CDAT, my client group will be male and female and are above 18 years of age. The
caseload I have in CDAT tends to be the more 'stable' portion of the client group and are
often being prescribed medication that won't be prescribed by the 'normal' community GP.
These patients will have often come through the “front door” of the service and been
treated and stabilised and are then passed on to me once stable.
My client group does include a very small proportion of homeless people.
02. What are the main reasons why your clients take drugs or drink excessively? Please tick all that apply.
If you work with more than one client group or you feel that there are other reasons as to why your clients take drugs or drink excessively, please comment in the box below.
§ A way to deal with stress;
§ Client(s) already substance reliant;
§ Mental health;
§ Environmental factors (for example – excessive drinking and/or drugs normalised in the home/community)
§ Relationship problems;
§ Self-medication;
§ Escapism.
Comments
As a general comment on the factors outlined[1] above and in view of my two main patient caseloads: The reasons for drug and alcohol misuse are almost always multi-factorial. About 30% of young men who become alcohol dependent, do so because they are treating an underlying anxiety disorder. The prevalence of past history of sexual and physical abuse amongst drug and alcohol misusers is significant and perhaps even more so within the prison setting. Within my CDAT role, I have a number of patients who fall outside of the above generalisations as they have become dependent on prescribed medications, often for chronic pain. Of course, there will be some aspects to the root cause of their misuse that may be similar to the wider group of those who become addicted.
03. Are there certain groups of people who are more likely to be affected by drugs and excessive drinking? If so, which groups might they be?
The evidence certainly links to deprivation and environmental factors that are already well documented, especially pertinent in South Wales.
- Poverty and crime
- Family members who take drugs or drink (generational)
- Past trauma (as mentioned previously)
- Overlap with mental health problems
04. Does a particular stage of your clients’ lives influence their likelihood of taking drugs or drinking excessively? If so, what stage might that be? (i.e. age, relationship breakdown, unemployment etc.)
This is hugely variable. Environmental factors include who they were brought up (taken into care, involvement with social services etc.) from a very young age and therefore having poor parental bonding to having to live with parents who drink or take drugs (and deal drugs) as well the trauma I have mentioned previously. Drink or drug use is highly prevalent and is socially acceptable (particularly alcohol). There is often cascade where there will be an overlap of factors including those mentioned above and subsequent availability that when further exacerbated by life-changing events such those you have mentioned, the situation is likely to escalate from the level of "social use" to that of harmful or dependent use. It is therefore the case that each story is indeed individual.
05. What barriers exist for your client(s) when trying to access support and services?
Regarding my role in CDAT: The main barriers are the multi-faceted services that are present within the community and although these attempt to work in partnership, quite often can be soloed in their approach. This means that as an individual's needs change there can be delays and duplication when moving from one service to another (e.g. through the various Tiers).
There is often a waiting list.
06. What barriers exist for services when trying to access support for client(s)?
The main constraint is funding and resource allocation.
The prevalence of the issues regarding substance misuse and alcohol misuse in Wales are probably under-reported and therefore under-resourced and these compound significantly with the overlay of deprivation as seen particularly in South Wales.
These hurdles seriously impede clients' progress and I suspect these thoughts would be echoed across the Health and Social Care sectors - housing, education etc.
07. What do you consider to be barriers for staff and frontline services in working with your client group(s), or substance misuse generally?
The client group is often quite challenging. However, the dedication and compassion of the staff often excels in order to compensate for this. This does ultimately lead (given the issues raised above) to burnout and low morale.
Because of the specialist nature of the work, deskilling in other areas can be can issues (e.g.
in nursing). There is poor overlap with other skilled workers and so there is an absence of the
networking normally associated with other parts of community and secondary care. In a
way, substance misuse services are seen to be separate from primary care and secondary
care and often appear to be kept at arm’s length even from the mental health services.
Recruitment and retention issues are present (given the issues raised above).
08. Where do you think efforts should be targeted to address the issue of alcohol and substance misuse in Wales?
1. The priority should be to rectify the resource allocation to treating those with substance misuse and alcohol problems. The evidence supports that the early intervention saves money further down the line in terms of other (more expensive) healthcare costs.
2. To address the increasing isolation of substance misuse and alcohol services and specifically the increasing use of private providers who deliver questionable value for money.
3. Improvements to the integration of the substance misuse and alcohol service more directly with primary and secondary care services.
09. In which local authority area do you work? If you work outside of Wales, please write your local authority area below.
Swansea.
Contact Details
Dr. Jake Hard
XXXXXXXXXXXX