Guidance for care home workers and providers

What are alcohol or drug problems?

We use the terms ‘alcohol and drug problems’ to mean the use of alcohol or drugs (substance use) that lead to significant problems or distress for the individual. Drugs include cannabis, heroin, cocaine or medicines such as methadone or benzodiazepines held without prescription. Signs of alcohol and drug problems include not being able to cut down or stop using the substance, spending a lot of time getting, using or recovering from use of the substance, and cravings or urges to use the substance.

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What is substance dependence?

In our research, we are particularly concerned with people with alcohol and drug problems who are substance dependent (also known as ‘addicted’) because our previous research suggests that they are at increased risk of poor care in care homes.  Signs of substance dependence include unsuccessful efforts to cut down or quit, lots of time spent using alcohol or drugs, intense craving for alcohol or drugs and having to use more alcohol or drugs to feel the same effects previously felt with a smaller amount.  In our research, we include people who are no longer drinking or taking drugs but may still be experiencing craving.

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Why don’t you use the terms substance “abuse” or “misuse”?

The terms ‘substance abuse’ and ‘substance misuse’ are being phased out because they are stigmatising and don’t have a precise definition.

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What are the care and support needs of people with alcohol and drug problems?

People experiencing alcohol and drug problems have varying care and support needs, many of which are the same as other people in care homes (e.g. engaging activities and help with personal care) but others relate specifically to substance use.

Some people have decided or to stop or greatly reduce their substance use, and others have already stopped using substances when they move into the home. Their support needs might include:

• support to access community drug and alcohol services
• detoxification, managed withdrawal, planned and supervised by a doctor who has the competencies and experience necessary
• support to maintain a reduction in their use of alcohol or drugs, including close supervision and an alcohol-free environment

However, some people are unable or unwilling to stop drinking/using drugs and choose not to engage with substance use services. The majority are assessed as having capacity to make their own decision on whether to continue their substance use. Care and support needs of people in this group might include:

• agreeing with the person what is (and isn’t) appropriate in terms of using alcohol or drugs in the care home, respecting their rights and autonomy as much as possible
• an approach where alcohol is treated as a medicine; this means spacing out drinks to manage withdrawal symptom and ensuring the person does not run out of alcohol and experience unsafe withdrawal
• monitoring for signs and symptoms of unsafe withdrawal or overdose and taking appropriate action
• helping to resolve ambivalence and encouraging belief in the ability to change
• supporting people with factors that may be contributing to alcohol or drug use e.g. depression, anxiety, trauma or loss
• ensuring people who inject drugs can access sterile injecting equipment
• administering prescribed methadone/buprenorphine for people dependent on heroin and other opioids

People may move between these groups because lapse (a short departure from a person’s other alcohol or drug goals) and relapse (where a person stops maintaining their goal of reducing or avoiding alcohol or drugs and returns to their previous level of use) is quite common, particularly in the early stages of recovery. However, not everyone will lapse/relapse.

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What might good care of people with alcohol or drug problems look like in practice?

We suggest that good care of people with alcohol or drug problems might include:

Good use of care plans

Care plans are very important because they provide a personalised, documented roadmap for a person’s care and act as a central communication tool for care home staff. They may include things such as the person’s goals in terms of their substance use, what has been agreed in relation to their substance use in the home, how they can be supported to avoid lapse/relapse and the risks associated with their substance use and strategies to reduce those risks. The care plan should be developed in partnership with the person and, if the person wishes, their family members.

Treating people with respect and dignity

Supportive relationships are essential when working with people with alcohol and drug problems. They should be treated with kindness, empathy and compassion and without judgement or blame. Research suggests that alcohol and drug problems are a result of an interaction between biological, psychological, and social factors. The addictive properties of alcohol and drugs make it difficult for a person to stop drinking or taking drugs.

Respecting a person’s autonomy

Autonomy is a fundamental aspect of good care for people with alcohol and drug problems. Trying to force a person to stop drinking or using drugs is unlikely to be effective and may be harmful. If a person has capacity to make their own decision about whether to continue drinking or using drugs, they have a right to make that decision, even if other people think it would be in their best interests to stop. However, it’s important to remember that a person’s motivation to change is not fixed. Just because a person isn’t ready to stop using alcohol or drugs now, doesn’t mean that they won’t in the future or that they would not consider strategies to reduce harm from their substance use.

Behaviours of concern

Just as people with other conditions such as dementia or brain injury sometimes find it difficult to regulate their behaviour and control their emotions, so can people with alcohol and drug problems. Some people are able to live in mainstream residential homes, others may do best in specialist homes. Supporting people might include working with them to understand the reasons for their behaviour, helping them learn the skills to manage their own behaviour, identifying, removing and reducing any trigger factors and implementing strategies to reduce the frequency, duration and impact of incidents.

It may also be helpful to set boundaries. These are the limits we have when it comes to other people’s behaviour. For example, you may draw the line at physical or verbal aggression, offensive language, damage to property or causing significant distress to other residents. When you have boundaries, it means everyone knows where they stand. It is important that everyone is clear about what the boundaries are and what the consequences will be if an agreed boundary is broken.

Reducing harm

Risk assessment is crucial for ensuring the safety and well-being of people with alcohol and drug problems. It involves identifying the risks and developing strategies to mitigate those risks. Risks might include issues which most care staff will be familiar with such as falls but others, such as overdose, seizures resulting from unsafe withdrawal and risk of harm to or from others, may require multidisciplinary risk assessment. Your local substance use service should be able to advise you on how to help the person reduce their risk of harm.

Supporting a person who wants to stop or reduce their drinking/taking drugs

Where a person is dependent on alcohol or drugs, safely cutting down or stopping alcohol or drugs should be managed by an appropriately trained professional. It can be dangerous to attempt to reduce or restrict a person’s alcohol or drug use without consulting with a doctor or a specialist substance use service. Without appropriate support withdrawal is less likely to be successful, is distressing and, in the case of alcohol dependence, can be life threatening. You can find the contact details of your local substance use service here. Substance use services can offer support (emotional and psychological) as well as medication that can reduce the risk of stopping drinking/taking drugs and the risk of relapsing. If necessary, a worker from the service should visit the person in the care home.

If the person is struggling with cravings, it may help to reassure them that cravings don’t last forever. It may help to think of them as a wave that builds up, peak and then goes away. You can try and distract the person when they are experiencing cravings. For example, listening to music, taking a walk or doing something creative. They may feel stressed, tense or worried. Simple relaxation tools like breathing exercises could help them feel better. Peer support from other residents who have recovered from alcohol or drug problems may also be helpful.

Supporting people who may lack capacity

Where the person may lack capacity to make decisions about continuing to drink alcohol/take drugs, the Mental Capacity Act should be applied. Just because a person may not have capacity to make some decisions does not necessarily mean that the person lacks capacity to decide about their substance use. Everything practicable should be done to support them to make a decision (e.g. simplifying information, presenting non-verbal information, giving them time to understand).

Substance dependence can affect judgement, but a wiliness to take risks (e.g. continuing to drink or take drugs despite harm) doesn’t automatically mean the person lacks capacity, a person lacks capacity if they are unable to understand and retain the information for long enough to go through the decision-making process, use or weigh that information or communicate their decision in any way (including sign language or blinking). A multidisciplinary assessment may be required, with the aim of balancing the individual's wish for autonomy against an acceptable level of protection.

A decision made under the Mental Capacity Act must be made in the person’s best interest. A best interest decision should be made in consultation with others involved in their care, for example relatives and health care professionals. Anyone making a decision on behalf of someone who lacks capacity must consider whether there is a less restrictive option. For example, reducing the strength or amount of alcohol and ensuring alcohol use is served and monitored by staff.

Appropriate staffing

People with alcohol and drug problems should be cared for in a home with an appropriate staff to resident ratio where staff have sufficient knowledge and expertise to meet their alcohol and drug related needs. The staff ratio and knowledge and expertise required will depend on the individual. For example, some people may need a high-level monitoring for signs of withdrawal or overdose and staff must be able to take appropriating such as administering naloxone – a medication that rapidly reveres the effects of heroin and other opioids. Other people may simply require support to access the local drug and alcohol service in which case staff would not require specialist knowledge or expertise. Staff should always work within their limits of knowledge and skills.

Staying within the law

The Misuse of Drugs Act 1971 makes it illegal for a person to possess, supply and possess illicit drugs with intent to supply. Under Section 8 of the Misuse of Drugs Act, managers of premises can be charged with offences under the Act, if they know that a prohibited activity is taking place on the premises (or in its environs) and ‘permitted or suffered it’ by failing to take reasonable and available steps to stop it (in other words doing nothing to stop it or turning a blind eye, but not mere suspicion).

Relevant prohibited activities under Section 8 are:

• Supplying, attempting to supply or offering to supply a drug to another person
• Smoking cannabis, cannabis resin or prepared opium

As a result of the way drug law has evolved, Section 8 only obliges managers of premises to take action in relation to cannabis or opium smoking. This obligation does not extend to the use of other drugs including Class A drugs such as heroin and crack cocaine. Therefore, a manager can know that a resident is using heroin or crack, and the manager is not themselves committing an offence if they don’t take action. However, they are committing an offence if they don’t take action in relation to smoking cannabis or opium. Action might include staff asking a resident to stop smoking cannabis or taking more robust action if the behaviour continues such as verbal or written warnings, acceptable behaviour contracts, termination of tenancy or police involvement as appropriate.

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