Substance Misuse in Forensic Practice in the UK

It is palpably factual that people with the severe mental health problem exhibit higher rates of co-morbidity particularly in the substance misuse (Chiringa, Robinson & Clancy, 2014). Citing from studies conducted in the UK, it is proved that there are higher rates of substance misuse within the UK population. Precisely, rates of co-morbid misuse of substance among the patients being admitted in hospitals/forensic departments range between 50 to 90 percent (Humber, Hayes, Wright, Fahy, & Shaw, 2011). Further, it has been recorded that there is continuous substance misuse even after admission which marks the major challenge endured by the forensic units. Thus, adhering to this case of a 24 years old man who exhibited aggressive disorderly behavior and substance misuse, there are several conclusions that can be drawn with regard to the association of mental health disorder and substance misuse. Some of the attributing factors include homelessness, inconsistent adherence to medication, severe psychiatric conditions, high treatment costs, and persistent contact with the law enforcement/ criminal justice system (Chiringa, Robinson & Clancy, 2014). Precisely, persistent contact with the justice system can be attributed by continued misuse of substance while in admission in forensic units thereby resulting to reconviction after the victim is discharged from the hospital. As a result, it can be asserted that the cause of aggressive disorderly behavior exhibited by the victim is strictly resulted by severe co-morbid substance misuse. It is worthwhile to state that there is a need for addressing the issue of substance misuse which can be conducted through clinical and law intervention as a control measure (Durand, Lelliott & Coyle, 2006). Therefore, this paper will offer an applicable forensic intervention of the substance misuse together with the law enforcement in order to mitigate the predicament to lower the heightening rates of co-morbid misuse of substance.

To start with, it is perceptible that the victim can be suffering from mental health problem that directed him to substance misuse and later to aggressive disorderly behavior in the public. As a result, the problem can be mitigated through clinical treatment particularly through psychosocial interventions (STEWART & BOWERS, 2015). Thus, one of the psychosocial interventions that can be employed includes inspirational interrogation with the aim of persuading the victim to change from the addictive behavior, counseling, and social skills acquirement through training. However, it is factual that using these psychosocial interventions to a person with co-morbid misuse of substance as the result of psychiatric conditions can be challenging. Consequently, addressing the problem on a healthcare perspective demands for extended interventions which include parallel, serial and integrated care (STEWART & BOWERS, 2015). Precisely, for parallel care, the problem is addressed by a group of specialists from different fields in order to determine the major cause of the problem to the patient and the applicable remedy. On the other hand, serial care encompasses addressing both psychological illness and misuse of substance by the patient consecutively in order to derive an appropriate judgment regarding the primary problem and its cause (STEWART & BOWERS, 2015). Lastly, integrated care encompasses the concurrent treatment given to the patient both on substance misuse and mental illness by specialists from a single field (healthcare). Therefore, according to the provisions of the national policy, the victim of substance misuse ought to be treated mental health services through the integrated care model (STEWART & BOWERS, 2015). The reason why integrated treatment is proposed by the national policy is based on the fact that it is regarded as the most effective treatment method for the co-existing misuse of substance associated with mental illness (STEWART & BOWERS, 2015). Thus, it is recommendable that the mental health staff included in the treatment of the victim has competencies particularly in recognizing the treatment of the problem with regard to the mental status of the patient. For the patient/victim using mental health service, their use of alcohol and drugs should be examined as part of Care Programme Approach (CPA) which should adhere to a single care plan in order to evade interfering with the criminal justice system to be enforced to the victim (STEWART & BOWERS, 2015). Generally, it is noteworthy that interventions for addressing the problem with the healthcare perspective should be staged with regards to the motivational and engagement stage correspondent to the level of need.  

Mental Disorder of Substance Misuse

Assessment of the mental condition of the detainee is vital prior to determining the general care to be offered to him/her. Examining the mental condition of the detainee will help the forensic physician to determine whether misuse of substance is the determining factor of the psychotic condition or the other way round. This is based on the fact that mental disorder and substance misuse co-morbidity has been very common in many cases that exhibit aggressive disorderly behavior of an individual (Carrà & Johnson, 2009). As a result, this can be regarded as the reason why diagnosis of drug addiction and diagnosis of schizophrenia coexist. Incessant drug use can result to deterioration of the mental condition of an individual even in stabilized psychotic disorder. Misuse of the substance is typically linked with psychosis with regard to several mechanisms. Precisely, intoxication determines the psychotic state which may be caused by stimulants and sometimes cannabis (Cullen, Jewell, Tully, Coghlan, Dean & Fahy, 2015). Therefore, it is noteworthy that a psychotic condition may persist to a level of being hard to eliminate the drug. On the other hand, withdrawal such as that resulted by alcohol might cause vivid hallucinations and loss of consciousness (Isherwood & Brooke, 2001).     

Treatment

There are four stages of treatment that are typically engaged in the diagnosis of the patient with mental disorder and co-morbid substance misuse. The first stage is the Engagement where the staff and the patient develop a therapeutic relationship together with the appropriate interactional style (Price & Wibberley, 2012). This is achieved by addressing the immediate problems of the patient rather than basically focusing on how to lessen the substance misuse. The second stage is Motivation which encompasses deep assessment of the substance misuse behavior exhibited by the patient citing from the theoretical perspective (Price & Wibberley, 2012). Therefore, the team involved in this treatment stage use different principles of motivational interrogation in order to encourage and persuade the patient to respond effectively. The third phase of the treatment is Active Therapy (Clark, 2009).  In this stage, the team offering treatment focuses solely on minimizing the substance use by the patient (Price & Wibberley, 2012). The last stage of treatment is identified as Relapse Prevention which is vital in a condition that exhibits chronic relapse of the disorder. According to the contemporary policy and guidelines offered with regard to the successful treatment for the patients with mental disorder and misuse of substance (Clark, 2009), the following are the elements that reflect treatment success.

• Long term support
• Enhancing a collaborative relationship with the patient and the staff
• Creating hope and trust in the patient/victim through inspirational interventions (Price & Wibberley, 2012)
• Substance consciousness work    
• Conducted a staged therapy in order to enhance patient’s motivation and willingness to change
• Comprehensive consideration of other needs of the patient such as finances, physical health and social status
• Prevention of the relapsing condition and other high risk conditions (Isherwood & Brooke, 2001)

 These elements are regarded as the qualities to which psychiatrics can be able to effectively offer therapeutic services to a patient with both mental disorder and substance misuse behavior (Moore & Drennan, 2013). Thus, citing from the fact that treatment of the two disorders is associated with co-morbidity and motivational interventions, integrated treatment is regarded as the most appropriate type of treatment for the patient exhibiting these dual disorders (Moore & Drennan, 2013).

Legal Framework

With regards to the considerations that the individual is a suspect at the police custody, there are several factors to consider in the delivery of humane response during provision of treatment and care (Durand, Lelliott & Coyle, 2006). It is exhibited that most of the detainees do not receive appropriate care if not treatment while at the police custody particularly because police tend to overlook the fact that the suspect is suffering from co-morbid misuse of substance. Therefore, one of the considerations that police fail to make for the suspects in detention includes the level of substance dependence.  As a result, one of the ethical principles in this case is precise assessment of the level and severity of addiction exhibited by the suspect (Durand, Lelliott & Coyle, 2006). Assessing the level of dependence is vital for the execution of medical intervention as it minimizes chances of risks based on psychiatric, medical and legal complications which are basically associated with intoxication and withdrawal (Durand, Lelliott & Coyle, 2006). Consequently, the reason why most detainees of substance misuse do not receive proper treatment and care is due to the fact that it is difficult to take accurate assessment together with an effective response to the problem endured by the victims.

Therefore, one of the considerations to be made while detaining the victim of substance misuse is based on their rights. It is factual that individuals under detention are entitled to the same standard of healthcare as other citizens (GREAT BRITAIN, 2013). This means that forensic physicians and police officers hosting the detainee ought to be cautious to the issue of detainee’s rights during examination.  According to Police and Criminal Evidence Act 1984 (PACE) Code H 2014, one of the rights of a detainee is to have a prescribed medication while at detention provided that it is clinically safe (GREAT BRITAIN, 2013). Additionally, it is the right of the detainee to have informed consent regarding the assessment and its results together with consequential clinical decisions.   

The other consideration that ought to be made with regard to the codes of practice to the detained individual is clinical safety of the suspect (Durand, Lelliott & Coyle, 2006). It is noteworthy that the attendance of the forensic physician is based on the health safety and welfare of the detainee. Therefore, it is vital for the detainee to be diagnosed for intoxication and withdrawal signs as one of the ethical principles of treatment and care to the detainee (Durand, Lelliott & Coyle, 2006). Thus, the forensic physician ought to consider that inception signs of overdose with the misused substance might not be immediately observed but they exhibit future possibility. In consideration of this, the custody staff ought to be given instructions regarding regular visit of the intoxicated detainee(s) for at least every half an hour to assess their conditions. Precisely, the detainees should be roused after every visit in order to record their response while trying to rouse them and if any change is noted on their level of consciousness, a medical treatment is arranged promptly (Durand, Lelliott & Coyle, 2006).

The third consideration to be made is based on the expectations of the detainee (Durand, Lelliott & Coyle, 2006). It is factual that the suitable medical treatment may not solely involve drugs prescription although most of the cases it is necessary. As a matter of fact, detainees ought to be helped to gain consciousness and comprehension on the usefulness of the prescription. Additionally, this is significant in realizing the preferences of the detaining and the reason behind the preferences (Durand, Lelliott & Coyle, 2006). This can be used to assess the level of addiction exhibited by the detainee. Assessing the level of addiction is based on the fact that dependence brings about confusion between medical care and supply of drugs.     

Conclusion

Generally, individuals with mental illness exhibit higher rates of co-morbidity especially on substance misuse. The rate of co-morbidity for these patients ranges between 50 – 90% of the mental illness patients. Thus, some of the attributing factors associated with mental disorder and substance use include homelessness, inconsistent adherence to medication, severe psychiatric conditions, high treatment costs, and persistent contact with the law enforcement/ criminal justice system. In the treatment of the man who was suspected to have been misusing the substance, there are several considerations to make with regard to clinical and legal concerns. These concerns include the rights of the detainee, the severity of dependence, possibility of relapsing state, clinical safety and expectations of the detainee. These are some of the things that custody staff ought to make while detaining the suspect.

References

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GREAT BRITAIN. (2013). Police and Criminal Evidence Act 1984 (PACE) 67(7B) - Code C: revised code of practice for the detention, treatment and questioning of persons by police officers.

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