INDEX

1. Substance Use Committee
   
2. Mentor role
   
3. Preventative education policy
   
4. Anaesthetists self care policy
   
5. Administrative control procedures
   
6. Signs of drug misuse
   
7. Investigation procedures.
   
8. Intervention guidelines
   
9. Intervention follow-up options
   
   

1 SUBSTANCE USE COMMITTEE


1.1 Committee composition
A Substance Use Committee (hereafter known as the Committee) shall be appointed on an annual basis by the senior anaesthetic consultations with the department, and shall comprise three members, including:

i) a senior anaesthetic consultant who shall facilitate the Committee;
ii) another anaesthetist;
iii) and an additional person who is not an anaesthetist, for example a DHAS representative or a substance use consultant.
The composition of the Committee will reflect its primarily administrative function, and will not necessarily be the same as the composition of the intervention team which is set up for therapeutic purposes (section 7.3).
The Committee shall require a quorum of two members. Each member of the Committee shall be required to notify the other two members if he or she is unable to attend a meeting of the committee, but will be able to nominate a proxy from within the department.


1.2 Committee responsibilities
This document and the responsibilities of this committee are primarily concerned with the misuse of drugs specifically more available to the anaesthetic profession and theatre staff. However all drug misuse is of concern, and may come within the committee's brief, for example alcohol misuse. The Committee's responsibilities include the following:

i) To safe-guard the interests of anaesthetists, health care workers (hereafter known as "staff") and patients by ensuring responsible drug handling.
ii) To promote preventative education on drug use
iii) To promote appropriate self-care policies and practices by staff
iv) To co-ordinate drug administrative control procedures
v) To receive and evaluate reports of drug misuse
vi) To co-ordinate investigation of reports of drug misuse which appear well-founded
vii) To develop contacts & a resource file for relevant treatment agencies and professionals
viii) To appoint an intervention team to counsel personnel who are found to be misusing drugs
ix) To monitor treatment and follow-up support
x) To co-ordinate the occupational re-training or re-entry into the workforce of drug misusers.
xi) to consult with those who negotiate re-entry contracts to ensure that appropriate provisions are included, e.g. supervision and monitoring of a recovering anaesthetist
xii) To write confidential recommendations to the relevant hospital authorities regarding the suitability of staff returning to employment following the treatment of drug misuse
xiii) To hold regular meetings, and other meetings on an ad hoc basis, when the need arises to consider a case of reported drug misuse.
xiv) To maintain confidential written records of reports of cases of drug misuse, and related information, including the results of treatment and outcomes.
xv) To conduct annual reviews of the effectiveness of preventative schemes, safety net policies and procedures.
xvi) To ensure that all parties, including hospital administration, are aware of the nature, epidemiology and outcomes of drug misuse.

2 MENTOR ROLE

Within the anaesthetic department at least one consultant should be appointed as a mentor by the Committee, to have a counselling, advocacy, liaison, feed back and referral role.
The mentor should not have managerial authority, nor be the director of training.
The mentor should have a knowledge and interest in substance use
The mentor should be appointed after consultation with the whole department (including all junior members) by consensus
the mentor or another person may wish to initiate and/or co-ordinate regular meetings of the department for support purposes, and to discuss stressful work-related issues.

3 PREVENTATIVE EDUCATION POLICY

The Committee will promote and co-ordinate comprehensive education on licit and illicit drug use and misuse (e.g. alcohol, marijuana, opioid drugs, tobacco) by staff. Preventative education would be directed towards encouraging overall health, and discouraging the potentially harmful misuse of anaesthetic drugs. Strategies include:
i) An operational plan of preventative education outlining goals and objectives, methods, core syllabus etc.
ii) Regular relevant input at tutorials, journal clubs etc.
iii) Regular relevant input at occasions involving partners
iv) Use of the skills and expertise of professionals from other disciplines in relevant areas

4 ANAESTHETISTS' SELF CARE POLICY

The Committee shall promote appropriate self care practices in all staff through education, managerial supervision, and other means including
i) Encouragement of twice yearly regular medical checkups with a personal general practitioner
ii) Encouragement of stress management and relaxation techniques e.g. regular physical exercise
iii) Active monitoring of workloads to avoid work-related stress; (anaesthetists' long hours to be reported to the anaesthetic department)
iv) Discouragement of self-prescription and self-medication, or by a close family member

5 ADMINISTRATIVE CONTROL PROCEDURES

The Committee will co-ordinate the implementation and monitoring of the following control procedures:
i) Restricted access (ensuring decreased availability) to chemical substances which may potentially be misused.
ii) Review of written records of all drugs ordered, dispensed, administered, damaged and returned unused, and the specific use for which they are intended, by comparing drug register and patient records.
iii) Organisation of random audits by a suitable person e.g. a pharmacist, to look for discrepancies or errors, and to ensure that drug use is consistent with patient need.
iv) The requirement for concrete evidence of breakage or damage, plus adequate explanation, before replacement drug is issued.
v) Opioid and no-opioid drugs with potential for misuse, together with the drug record, to be lock in a secure cupboard, which requires the sue of two keys to open.

6 SIGNS OF DRUG MISUSE

6.1 Major Signs
One or more of the following signs of drug misuse may be considered sufficient to justify a report of suspected drug misuse; should such signs be observed in a staff member, it is mandatory to make an immediate report to a member of the Committee or a mentor.
i) A staff member signing out increasing quantities of drug, or quantities of drug which are inappropriately high for the use specified.
ii) Increasingly illegible, inaccurate or otherwise inadequate or unusual record-keeping
iii) A consistent pattern of complaints regarding excessive pain, by recovery or was staff, in patients of a particular anaesthetist. Pain is out of proportion to the recorded amounts of analgesic drug given
iv) Reports of change in attitude or behaviour
v) Observation of tremors or other withdrawal symptoms
vi) Observation of intoxicated behaviour
vii) Observation of pills, syringes, ampoules, or other evidence of drugs in any non-workspace environment, e.g. at home or in the change room
viii) Observation of injection marks on the body, bloody swabs, tissues or intravenous equipment in any non-workspace environment.
ix) Direct observation of diversion, self-administration, misuse of anaesthetic drugs, or falsification of records

NB Further clarification of major signs may be obtained by reference to DSM IV (Diagnostic and Statistical Manual of the American Psychiatric Association) Criteria for Psychoactive Substance dependence and Diagnostic Criteria for Opioid Withdrawal.



6.2. Circumstantial signs

The following signs may be considered sufficient to arouse suspicion of possible drug misuse, or even to justify a report of drug misuse if observed in a developing pattern:
i) Significant changes in behaviour, presentation, personality or emotions, e.g. sudden social withdrawal, increased isolation or elusiveness, deterioration of personal relationships, development of domestic turmoil, overspending, increasing time in the bathroom, decrease in reliability, decrease in sexual drive, wearing long-sleeved gowns in theatre or warmer clothes than necessary, wide mood swings, periods of depression, euphoria, caginess or irritability, or the smell of alcohol on the breath;
ii) Intoxicated behaviour, pin point pupils, weight loss, pale skin, sensitivity to temperature, elaborate rationalisations of conduct, more accidents or mistakes, deterioration in personal hygiene, numerous health complaints, impulsive behaviour.
iii) Increased sick leave or other absenteeism, unavailability, irregular hours, working alone, tardiness, refusing breaks, willing to relieve others, volunteering for more cases or more on call, remaining at the hospital when off duty, personally administering medication normally others' responsibility, unsatisfactory work records (frequent moving or changing jobs), inappropriate conduct.

7 INVESTIGATION OF A SUSPECTED CASE OF DRUG MISUSE


7.1 Reporting a suspected case of Drug Misuse

A suspected case of drug misuse for investigation can be presented as an oral or written report to a member of the Committee or a mentor by:
i) Any member of staff, a spouse or, a member of the general public, or any member of staff concerned about his or her own drug use.
ii) A member of the Committee or a mentor may initiate an investigation if he or she considers there to be sufficient evidence to do so. In all these situations, the reporter's identity will remain confidential.
iii) The Committee member or mentor will provide a written report to the Committee, detailing the basis upon which the report was made. The Committee will then assess whether the case falls within the guidelines of 6.1 above. If the matter is not considered urgent (i.e., no major signs present as in 6.1), the report will be tabled at the next scheduled meeting of the Committee.
iv) If the report is considered by the Committee member to require urgent attention (i.e. there are major signs of substance misuse as in 6.1) then an urgent meeting of the Committee is to be convened, which will take place within 24 hours of receiving the report.


7.2 Investigation of a suspected case of Drug Misuse

The Committee will evaluate the written report of drug misuse and decide upon appropriate action:
i) If there is sufficient reason to suspect an individual of drug misuse (major signs as in 6.1), immediate investigation will be initiated
ii) If there is sufficient evidence of circumstantial signs (as in 6.2), the situation will be monitored, and the case considered at the next regular meeting of the Committee.
iii) If there is insufficient reason for suspicion, the case will be dismissed
iv) The decision agreed upon and the subsequent action shall be recorded and stored in a locked filing cabinet. Access to this cabinet will be restricted to Committee members and the mentor.

Investigation and verification of a written report of drug misuse could include:
a) Discreet checking of written records and drug stocks in drug storage cupboards for any evidence of diversion, falsification, or discrepancies in accounting for use.
b) Discreet checking of time sheets, patient files and other records for evidence of drug misuse. If necessary there should be confidential enquiries of a limited number of staff and patients, concerning observations of behaviour or speech in the suspect.

7.3 Appointment of an Intervention Team

If the Committee is fully satisfied that there are good grounds to continue the investigation, it shall appoint an Intervention Team to conduct a meeting with the staff member under suspicion. The Committee must make clear to the Intervention Team the possible preferred option (see 9 below).
i) A member of the Committee
ii) One other person who could perform an advocacy role e.g. a mentor
iii) A DHAS representative or a drug counsellor
iv) A mental health professional experienced in this field

It is the responsibility of the Intervention Team to ensure that the emotional and other safety needs of the person under investigation are met. The team should ensure that the individual being interviewed has a support or advocacy person of his or her choice present (e.g. partner, friend or social worker)

8 INTERVENTION GUIDELINES

The Intervention Team should conduct an intervention firmly and sensitively, aware of the need to take into account the interests of patients as well as those of the person under investigation. The following steps are suggested as a minimum:
i) Thoroughly prepare the evidence, a combined strategy, a venue for the meeting, and if necessary an immediately available detoxification program
ii) Tell the person under investigation of the need for an immediate meeting.
iii) Ensure the person under investigation is accompanied by a member of the Intervention Team or another qualified person from the time he or she is informed that an intervention meeting will take place
iv) Ensure the person under investigation knows he or she can have a support or advocacy person of his or her choice present at the intervention meeting, if such can be arranged expeditiously.
v) At the meeting, re-introduce the personnel present and explain the purpose of the meeting; do not get side-tracked from this purpose.
vi) Describe in detail the specific evidence that has led the Committee to make the intervention (present the facts and their consequences clearly without making personal judgements)
vii) Outline the options available (section9) in accordance with those preferred by the Committee, emphasising the possibility of voluntary engagement in treatment.
viii) Listen to the response of the person under investigation, and of the supporter or advocate. Reassure the person of continued support during treatment, and in re-training or re-entry to the workforce.
ix) At the end of the meeting, ensure the person under investigation is either escorted by a member of the Intervention Team to the detoxification unit, is reported to the police, or is treated according some other appropriate option.
x) Inform the Medical Council of the circumstances and action taken
xi) Record the results of the intervention meeting, report it to the Committee, and file a confidential record.

9 INTERVENTION FOLLOW UP

The Committee can choose from a variety of follow up options after the intervention process. These include:


9.1 Immediate follow up options

i) Voluntary admission to a medical detoxification unit.
ii) voluntary attendance as an outpatient or inpatient at a drug dependency or psychiatric unit.
iii) Involuntary treatment e.g. committal under the Mental Health Act
iv) Report to the appropriate hospital authorities for the purposes of liaison, work suspension or dismissal
v) Report to the police, or initiate legal proceedings for theft, professional negligence or breach of contract, under the various relevant Acts


9.2 Post treatment options

i) Re-entry into the workforce in the same discipline
ii) Re-direction or re-training for an alternate career