Substance use amongst inpatients on mental health wards: practical guide for mental health services

10. Reviewing patients who use substances on the ward

It is fundamental that patients that use substances do not feel isolated, stigmatised or discriminated against.

Using substances while on the inpatient ward may disrupt the treatment of the patient and so patients should be supported, wherever possible, to address their substance use. Substance use on the ward may also lead to disruptive behaviour and expose others to risk of harm.

Staff should follow existing local guidance on the management of aggressive or violent incidents, regardless of whether substance use is suspected or confirmed.

Staff must inform patients on the options available to them regarding treatment and support for their substance use. Patients should be informed of the impact that substance use may have on their treatment on the ward. This should include explaining to the patient and their family, if appropriate, that they may be discharged if their substance use cannot be safely controlled on the ward, or if they pose an unmanageable risk to others.

Early or unplanned discharge should be the last resort, and should only be in response to an unmanageable risk to the patient or staff and other patients on the ward. The decision to discharge a patient should be based on a multi-disciplinary discussion and assessment of risk. Specifically this assessment should record:

• The risks of an earlier than planned discharge versus ongoing inpatient stay.
• Where the patient will be discharged to and a follow up care plan.
• Circumstances and context including the views of the patient and next of kin/nearest relative/relevant others (where consent has been given to share information).
• The time when substances were taken.
• If substances were taken as a single dose or staggered.
• The potential interactions or additive effects of the substance taken with prescribed medications.
• If alcohol was consumed.
• The patient’s presentation following substance use.
• A statement about the likely delayed effects and potential lethality of the substances taken, (for example the need to consider respiratory depression in opiate use).
• The risks to others on the ward. This would include any risk to vulnerable individuals being exposed to substances.
• The risk of patients and staff being exposed to distressed/adverse behaviours/ violence as a consequence of substance use.
• Considerations with regards to the use of the Mental Health (Care and Treatment) Act 2003 (please see the MWC guidance on drug induced psychosis).

The risk assessment should balance the risk of continued inpatient care against the impact of discharge to the patient regarding their treatment for their mental ill health and the risk of discharge to their health and safety. These discussions should be carefully documented in the clinical record.

It may be helpful to conduct these discussions in the format of a clinical pause which supports multi-disciplinary discussion. A record of who was involved in the discussion should be made.

In cases where a patient is discharged, a comprehensive care plan should be put in place ahead of discharge which addresses the patient’s mental health and substance use needs. This should be undertaken collaboratively with a multi-disciplinary team to ensure the patient remains safe and clearly understands how their care will proceed. This includes arrangements for medication supply and community follow up.

Transitions can be a high-risk time for overdose, especially if the patient has been using less substances while on the ward than they would normally. It is imperative that the risks of overdose are explained to the patient, that they have a care plan in place to support them with their drug use, and that they are provided with Naloxone.

The Strang report found that families felt the needs of the patient were not met when they were discharged as a result of substance use on the ward. If permission has been granted, staff should involve family members, explain why the decision has been taken to discharge the patient and how the patient’s care will subsequently be managed.

The risk of overdose should be explained to the family and, if it is appropriate for those who have problem use of opiates, they should be provided with Naloxone and informed of how they can access it. If distributing Naloxone, staff should advise families to complete the online training on administering Naloxone via the Scottish Families website.