Prescription for security

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 -ʔwe 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.”