CASE NOTES

The name of the service user has been changed

Practitioner:  Jim McBride, community addiction manager, and Paul McGivney, nurse team leader.

Field: Addiction services.

Location: Glasgow.

Client: Vincent Muir is a 22-year-old young man who has been attending a methadone clinic for some time and has been reasonably stable. 

Case History: Recently, Muir arrived at the community addiction team (CAT) offices after having missed his clinic morning appointment because he had spent the night in a police cell. There was no one to see him - his methadone could not be brought to the offices until later that afternoon and his probation social worker was out. Standing near the door to the staff area Muir was asked by two workers to move away. Initially he was calm but then he quickly became aggressive and threw a punch at one of the workers. Muir left but was due that afternoon to collect his medication. 

Dilemma: Given Muir's aggressive and threatening behaviour, managers would need to balance their duty of care for him - given he hadn't exhibited such behaviour previously - with the need to protect staff and other service users.

Risk factor: Muir, withdrawing from methadone, may seek street heroin or other substances that will affect his behaviour.

Outcome: On Muir's return the situation was handled by managers. After the event he said he could not remember the incident and was remorseful for his behaviour. Unrelated to this incident, he was later remanded in custody for carrying an axe.

Those working in addiction services are required daily to work effectively with drug users. And violence, whether potential or real, can be part and parcel of the job.

Although Glasgow has made some progress on safety, with the highest stabbings per head of population than anywhere else except Northern Ireland and Finland, there is clearly some way to go. Indeed, with the drug and knife cultures feeding each other, the Scottish executive last year introduced tougher measures on weapon carrying.

Perhaps less dramatic, but equally challenging for staff in Glasgow's community addiction team (CAT) in the city's east end is the recent trend of drug users moving from one drug of choice to a mix-and-match mentality.

"Drug culture has meant that people we have worked with who are not historically known for volatile or aggressive behaviour are now presenting quite differently," says community addiction manager Jim McBride. "Some of that is about people preferring a concoction of substances."

Vincent Muir, 22, regularly attended a methadone clinic as part of his programme to come off heroin. But having missed his methadone clinic appointment because he had been arrested, he turned up at the CAT offices looking for his medication. After he was given a 3pm appointment, he became aggressive and attempted to assault one of two workers (neither of whom was working directly with him). He then left.

On his return to the offices Muir "wasn't thinking straight," says nurse team leader, Paul McGivney. "I had his prescription and left him a message that I'd bring it back to the office later that afternoon. Obviously he's going to get more uptight with more hanging about to do - because he'd have to wait about three hours."

It was time that had to be filled in some way. "Before he returned he had probably been drinking a bit and more likely had been taking substances on top of that. So he was in a bit of a state, and I'm thinking whether or not I should give him the prescription. But it's Friday afternoon and if I don't give it him then he has no methadone for four days - so he's going to be worse: and possibly go looking for street heroin. We don't have screening facilities so I can't see what he's already had. I could take a urine sample but that only says that somebody has a substance in their system, it can't quantify it."

Given his earlier attempted assault, McGivney and McBride decided to meet with Muir on his return -Ê"we took the lead because we're managers and that's what we're there for".

McBride continues: "There were also question marks over his mental health and it was difficult to gauge him. We were caught with a dilemma of a duty of care and at the same time violence to staff issues. Staff were spoken to and de-briefed, and were interviewed by police and had the option to press charges if they wished. We said either way we will support you."

At first aggressive, Muir calmed down knowing his prescription was there. McGivney challenged him about his behaviour: "He was at a bit of a loss and became very emotional. He clearly felt that the best plan of action and only option open for him was to be put in prison. Perhaps he felt that partly because of his intoxication, or partly because of his withdrawal from methadone."

"He talked about prison being the safest place for him," adds McBride, "because it was structured and he had pals there - that was the sort of reference he was making to us."

His probation social worker visited him later and Muir claimed that he had no recollection of the incident, which the worker believed. Muir has since been placed in custody on remand for carrying an axe.

For McBride, the incident was a strong reminder of the wider issue of the knife culture and violence that can be associated with the addiction client group. "It's about being more aware as staff. It's one thing to have a service user being verbally abusive but we simply don't know what they are carrying."

However, he is quick to qualify that this was only the second such incident in six years. "And that's partly because we treat people with respect, but also generally because people want to come and see addiction staff: it's more likely that people think 'They're here to help me', rather than 'I'm here to see you because I'm told to'. But we can never underestimate the unpredictability of service users."

Independent Comment
There are number of serious issues that needed managing in this case study, writes Andrew Horne.  

Uppermost in the managers' minds was the safety of the service user and the staff. Their equal concern for both is admirable. They showed personal concern for the predicament of the service user and an understanding that retaining people in service is the best way to successful treatment.

There is fine balancing act between working with challenging people and creating secure resources. I have always resisted the latter as it can create a "them and us" atmosphere. But there is increasing reliance on physical barriers, video surveillance and electronic panic devices. Our work uses an array of communication skills to work with people. Direct access services need to be welcoming, warm and informal. These are important principles to be retained. 

In 20 years I can count on one hand the number of violent incidents directed at staff. I, too, have supported staff to press charges. But I now insist we press charges for two reasons: first, an illegal act has taken place and a legal response is needed with the matter then lying with police and the courts.  Second, it warns the perpetrator and other service users that assaulting staff will be taken seriously. But taking this action does not mean that we should withdraw service from the person who challenges. 

The managers worked well together by supporting the staff, leading by example and supporting the service user.  A job well done.

Andrew Horne is operations manager, Addaction Scotland. Addaction is a leading UK charity working solely in the field of drug and alcohol treatment. 

Arguments for risk

• Clearly McBride and McGivney needed to assess the risks Muir posed to staff and service users, but also the risk to himself. The police attended - which Muir may well have suspected - but remained in a back office.
• Although aggressive at first, when challenged about his behaviour Muir broke down and said his confusion about his experience was because he was in and out of prison.
• The managers made sure that all staff were debriefed after the event, following staff procedures and filing a critical incident report (which helps inform how future practice can learn from the experience). "It was also raised as a team issue. We are conscious of seeing changes in people's behaviour with mixtures of crack cocaine, heroin, cocaine and alcohol, and so on. Folk who had never shown any major issues about aggression are all of a sudden starting to be quite different in their presentation," says McBride. 

Arguments against risk

• Territorial violence in Glasgow instils an attitude that you have to carry a weapon - usually a knife but swords are increasingly used. "Ironically, one of the things that has broken that territorial barrier is drug use - because people have to buy, move and take drugs, which means that those people are having to carry for protection and intimidation," says McBride.
• Muir's behaviour is linked to missing his medication - so why did the police allow this  to happen? "If a person has a prescription, police should contact a GP or police surgeon to make sure that the person gets their medication. But about a thousand people in the east end alone are on methadone," says McBride. "So given the traffic that goes through police stations, it is very difficult at times to ensure that folk are getting to the chemist. Quite often police officers will pick up their methadone prescription or make sure that it's administered. But sometimes there just isn't time."