6 Hospital Services

6.1 Some drug misusers will present to hospital for antibody tests, or once they are showing symptoms of HIV-disease. Others, who may or may not be infected with HIV, undergo detoxification in general medical or general psychiatric wards. All people who become ill with HIV-disease will need in-patient hospital treatment at some time, and currently most of the expertise in understanding and treating HIV-disease lies with hospital staff. It is probable that HIV-disease will soon impinge on every hospital specialty. For the immediate future, those hospital specialties most likely to encounter drug misusers with HIV-disease include Genito-Urinary Medicine (GUM) Clinics; HIV Counselling Clinics; infectious diseases units; general medical wards; maternity services; Accident and Emergency services and, to a lesser extent, surgery.

Drug Dependence in Hospitals

6.2 Wherever drug misusers present in hospital, it is important that their drug needs are understood and taken account of. If hospitals have failed to establish a policy for managing drug dependency on the ward, it is possible that an ill drug misuser could be admitted and start to undergo involuntary withdrawal before drug treatment is administered. In these circumstances, the individual might discharge him or herself when in poor physical and emotional health, and would be reluctant to enter hospital again in the future. Additionally it is important that medical and nursing staff should understand the effects of drug dependence on an individual's tolerance to pain-relieving drugs. Opioid dependence may mean that considerably higher doses than usual are needed. This has particular implications for drug misusers with HIV-disease who receive terminal care in hospital. Hospital managers should ensure that a policy is in place for treating patients who are dependent on drugs and that medical and nursing staff understand, or have access to advice on the implications of drug dependence for the administration of pain-relieving drugs.

GUM Clinics and HIV Counselling Clinics

6.3 Drug misusers are already presenting at GUM clinics and HIV counselling clinics for HIV antibody testing. Some of these people will have been referred by GPs or drug services, others will come on their own initiative. Clearly, the staff in these clinics will need an understanding of drug misuse and its implications if they are to offer pre- and post-test counselling or continuing health monitoring for drug misusers and ex-users. Staff should also accept a responsibility to ensure that drug misusers, regardless of their test result, have access to treatment for their drug problem, and basic primary health care. Staff should actively encourage clients to register with a local GP, if they have not yet done so, even if they are only intending to remain in the area for a short time. If they are still misusing drugs, and are not receiving treatment for this, staff should, with individual clients' agreement, refer them to a specialist drug misuse service. Where a significant number of clients of a service are drug misusers, it may be advantageous to have a specialist drugs worker on site for at least part of the time. We therefore recommend that staff in GUM Clinics and HIV Counselling clinics are trained in working with drug misusers; that such services should develop rapid two-way routes of referral with specialist drug services; and that a specialist drugs worker should spend some time working on-site in areas where significant numbers of clients are drug misusers.

Other Hospital Out-patient Clinics

6.4 We have already emphasised the importance of regular health monitoring for all people with HIV disease. In most cases, such checks will be carried out in an out-patient clinic, probably associated with GUM or infectious diseases facilities, and sometimes this work will be on a shared-care basis with GPs.

6.5 Some drug misusers are bad at keeping appointments; they might fail to turn up, or might appear at the wrong time. Occasionally, a current misuser may arrive for an appointment intoxicated or in a state of drug-induced confusion. Some of these mental states may be difficult to differentiate from HIV-related dementia, which may also result in forgetfulness and disinhibited behaviour. Out-patient services will need access to expert advice on both drug dependence, and psychiatric illness, and should be able to cope with manifestations of either or both in their patients. One of the implications of this is that considerable flexibility in appointment systems will be needed.

Management of Drug Misusers as In-Patients

Developing Skills

6.6 As HIV-disease among drug misusers becomes more prevalent, hospital staff will find themselves providing medical care for ill people who are continuing to misuse drugs. Many staff will have to adopt new attitudes and approaches to manage current drug misusers.

6.7 Specialist services for drug misusers have specific staff skills for dealing with drug misusers, but may have less experience of managing people who are ill with HIV-disease. Conversely, staff on hospital wards, whether general medical or specialist wards such as an infectious disease unit, may need specific help and advice on how to manage patients who are drug misusers. One productive method of improving skills in both settings is for the two services each to develop a training programme for the other. In conjunction, the two disciplines can develop the best method of managing ill people who are still misusing drugs.

6.8 Where there is a need to have a more specific specialist advice or input, the ward consultation service could be used whereby all ward specialties help other specialties. Thus staff on a ward or in a particular treatment unit should be able to call on the ward consultation service for a doctor, nurse, psychologist or counsellor to help manage an individual case. This service would be no different from the existing ward consultation service practised in all hospital settings, but it should widen the service to use staff other than medical staff.

6.9 An enhancement of this specialist input could be made by the use of regular sessional input, both to manage individual patients more effectively and to emphasise teaching and education of staff. For example, the local specialist drug team or drug clinic could arrange for a member of staff such as a CPN or psychiatric registrar to carry a specific sessional input on the requesting ward or unit. This specific and formal sessional arrangement should be established wherever real needs of training and skills are required that cannot be easily improved by informal arrangements such as those outlined above.

6.10 The mental health services may already need to provide for people with HIV-infection who have developed psychological and psychiatric disturbance. Though as yet there is not a major demand, experience from the United States suggests that planning should now be put in hand for development of psychiatric hospital facilities for the management of HIV-related dementia.

6.11 Furthermore, there may be need in certain circumstances for consultant staff or their deputies formally to share management of the case. For instance, there could be one consultant in overall charge, but a second consultant (eg a psychiatrist in charge of a drug service) could be closely involved on a day-to-day basis with the management of the drub problem. It is quite common in other areas of medical practice to have joint care of complex cases, but it is unusual for drug specialists to become involved.

6.12 In conclusion, the advent of HIV-disease demands much greater integration of care between medical and drug services than has happened in the past. Hospital staff should take steps to ensure that expertise on the management of drug misusers is available on the ward. The extent to which integration takes place will depend on local services and the prevalence of HIV-disease among drug misusers in the area.

Effective Management of Individuals

6.13 We have emphasised that the stereotype of the `difficult' drug misuser is unhelpful and not usually borne out in reality. Nonetheless, a minority of current drug misusers may behave in a way which causes problems on hospital wards. It has been known for drug misusers to steal hospital or personal property; to use street drugs while on the ward; and for their friends to smuggle illicit drugs in and licit ones out. Some are not readily compliant when it comes to accepting treatment or therapy, and some may wish to discharge themselves early. Most drug misusers will cause no such problems, but the few who do may cause disruption on a ward if difficult situations are not properly handled.

6.14 Many of the problems outlined above can be minimised or avoided by good management. Wherever possible, ward staff should be trained and experienced in working with drug misusers. Where this is not possible, specialist drug services should offer advice.

6.15 To maintain the smooth running of the ward, staff may find it helpful to negotiate with drug misusers about acceptable standards of behaviour. Most drug services have found that the few potentially troublesome patients comply with and respond better to treatment when aware of clear boundaries with respect to their treatment and behaviour. For example, staff might point out that unapproved drug use; stealing; drinking alcohol; violence; or threatening behaviour are unacceptable and will incur sanctions. Possible sanctions could include stopping or placing specific restrictions on visitors, or limiting access to other parts of the hospital, but should be individually and privately negotiated as they will depend on specific circumstances. The most effective system for a particular ward or clinical setting will evolve or develop according to local practice and circumstances. However, in all cases negotiations should take place as soon as possible after admission, because difficulties can be anticipated and avoided if these sensitive topics are discussed in advance of a crisis. In any case, it is extremely difficult to start to implement a `contract' system with a patient who was admitted some time ago, and is now convalescing. Negotiating contracts will not be suitable in all cases, but they have proved valuable in operation by many psychiatrists and clinical psychologists who may be able to offer advice on implementation in individual circumstances.

Segregation or Integration?

6.16 The question of whether or not people who are misusing drugs should be separated from other patients is a difficult one. Some drug misusers can behave in a way that upsets or disturbs other patients and staff, and there are dangers that this will cause a backlash of hard feeling against drug misusers in general. If it is necessary to apply a `contract' system in individual cases then rules about visitors, access to other parts of the hospital, etc, may be different for those individuals. Staff may find it difficult to accept the concept of differential treatment and it might seem to be in conflict with a ward's overall philosophy and atmosphere of care, calm, support, and acceding to patients' wishes wherever possible. Also, drug misusers do have special needs, and integration of services could result in these needs being overlooked. It can therefore be argued that in the interests of drug misusers, staff and other patients, separate services should be developed for ill drug misusers with HIV-disease.

6.17 On the other hand, this could be seen as further isolating and alienating drug misusers. There could be difficulties in defining "drug misuser", and some people could be annoyed and offended at being categorised in this way. Also, in areas where there are either very few or very many drug misusers with HIV disease, it may not be practical to develop separate services. Acute care should be offered to people according to their need regardless of whether they are dependent on drugs.

6.18 In areas with high prevalence of drug misusers with HIV-disease we have heard of difficulties that can be encountered when several drug misusers are on the same ward, because of the tension between them. One hospital has found that mixing sexes on the ward reduces conflicts. We believe that many difficulties can be similarly minimised or overcome with management training and experience. We acknowledge the strengths of the arguments in favour of segregation of drug misusers from other patients, but we support the concept of integrated care, and believe that segregation should not be a starting point for services.

Discharge from Hospital

6.19 The transition between hospital and community is an important one. Unless links with community services are forged before the patient leaves hospital, it is easy for the responsibility for care not to be transferred at all. Before drug misusers with HIV-disease leave hospital, their needs should be assessed and suitable arrangements made with community-based services. We have heard evidence of an excellent system working in the Ruchill Hospital, Glasgow, whereby two community nurses are able to discuss a patient's needs with that individual and hospital staff, and arrange for individually-tailored services to be provided, including access to specialist drug services. Having staff working full-time on this "co-ordinating" role means that they are able to develop skills in assessing needs, and establish a constructive, continuing relationship with other services. Staff other than nurses could be suited to this role; social workers in particular often undertake this type of work. What is important is that there should be a planned transition into the community rather than a straightforward discharge from hospital.

Maternity Services

6.20 At present, most seropositive women who become pregnant are drug misusers, ex-users, or the partners of drug misusers. Maternity services — except in Edinburgh — are currently only seeing such women in small numbers, but numbers are bound to increase, raising many considerations for the service provided. Up to the end of September 1988 some 950 women, of whom 490 were injecting drug misusers, had tested positively for HIV in the UK, and this probably represents the tip of the iceberg. All these women are likely to be of childbearing age. In Chapter 3 we drew attention to the importance of sensitive, balanced counselling on HIV-disease and pregnancy being available to seropositive women who are pregnant.

6.21 Current or ex-drug users are frequently anxious that their childdren will be taken into care, and so may avoid statutory services as far as possible. This means that they often present late to services when they are pregnant, in the second or even third trimester. Sometimes they are referred by specialist drug services; it is advantageous for there to be good two-way referral systems between the two services.

6.22 Drug dependence requires careful management in pregnancy, for the health of both mother and baby. Sometimes pregnancy will spur a woman to stop using drugs, and if she presents early enough, the hospital may be able to arrange a controlled detoxification (foetal as well as maternal reaction must be monitored and controlled). If the woman presents too late for a safen detoxification, or is unable to contemplate stopping using drugs, then prescribed substitute drugs may be valuable in stabilising health and behaviour. In these circumstances precautions must be taken to counter withdrawal symptoms in the baby after birth.

6.23 When a seropositive drug misuser and her baby are discharged from hospital, it is important that adequate links are forged with services in the community. A midwife, health visitor or other nominated person should ensure that:

i. arrangements are made for a health visitor who is specially trained in drug misuse and HIV-disease to attend mother and baby, and that paediatric supervison is available;
ii. the woman clearly understands what follow-up arrangements are in place for monitoring her health, and the health of her child. With her permission, these arrangements should also be conveyed to her general practitioner (if she does not have a GP she should be helped to register with one);
iii. the woman is put in contact with a specialist drugs service;
iv. the woman receives any help she may need with social security benefits or other practical needs.

6.24 Although women may present with a mistrust of services, experience in Edinburgh and Milan has shown that a good, trusting relationship can be developed, and in these circumstances the mother is much more likely to remain in contact with services after the birth.

6.25 It will be clear from the above considerations that maternity services will need to adapt in a number of ways to meet the needs of seropositive drug misusers. We therefore recommend that:

i. in areas of high prevalence of drug misuse, maternity staff should be trained in managing pregnancies in drug misusers. Specialist advice should be available to those areas without this expertise. In all cases there should be good two-way referral systems between obstetric and specialist drug services.
ii. Maternity services should be prepared to operate their appointment system flexibly when seropositive drug misusers present late in their pregnancy, and to see these women quickly.
iii. Health care plans should be in place to ensure that when a seropositive woman and her baby leave hospital, they have access to adequate help from medical and social services in the community.