The Assessment of Claimants with Drug or Alcohol … Assessment of Claimants with Drug or ... The Assessment of Claimants with Drug or Alcohol ... Mental and behavioural disorders

Training & Development

The Assessment of Claimants with Drug or Alcohol Problems

MED-S2/CMEP~0036

Module 15

Version: 7 Final 16 April 2014

ATOS HEALTHCARE

PROVIDED ON BEHALF OF THE DEPARTMENT FOR WORK AND PENSIONS

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MED-S2/CMEP~0036 Page 2

Foreword

This training has been produced as part of a programme for Health Care Professionals (HCPs) approved by the Department for Work and Pensions Chief Medical Adviser to carry out benefit assessment work.

All HCPs undertaking medical assessments must be registered practitioners who in addition, have undergone training in disability assessment medicine and specific training in the relevant benefit areas. The training includes theory training in a classroom setting, supervised practical training, and a demonstration of understanding as assessed by quality audit.

This training must be read with the understanding that, as experienced practitioners, the HCPs will have detailed knowledge of the principles and practice of relevant diagnostic techniques and therefore such information is not contained in this training module.

In addition, the training module is not a stand-alone document, and forms only a part of the training and written documentation that HCPs receive. As disability assessment is a practical occupation, much of the guidance also involves verbal information and coaching.

Thus, although the training module may be of interest to non-medical readers, it must be remembered that some of the information may not be readily understood without background medical knowledge and an awareness of the other training given to HCPs.

Office of the Chief Medical Adviser

April 2014

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Document control

Superseded documents

Version history

Version Date Comments

7 Final 16th April 2014 Signed off by HWD and CMMS

7a Draft 18th February 2014 Schedule 28 update

6 Final 11th July 2013 Signed off by HWD and CMMS

6a draft 5th July 2012 Schedule 28 update

5b Draft 7th July 2011 Comments from customer incorporated by Medical

Training & Development

5a Draft 21st June 2011 Updated by Medical Training & Development, following

Schedule 28 review

4 Final 22nd

July 2010 Signed off by Medical Services Contract Management Team

Changes since last version

Foreword updated

General updating of layout and formatting throughout

Term examination amended to assessment where appropriate

Page 7 – additional information on MCQ added

Page 8 – paragraph on stigmatisation added

Page 9 – DSM-IV updated with DSM-5 criteria and more information on ICD-10 added

Page 12 – Information on unit of alcohol added

Page 13 – additional information on units of alcohol in various drinks added

Pages14, 18, 19 – information on statistics updated

Page 15 – additional physical conditions added

Page 27 – self harm is added to risk factors

Page 28 – hospital inpatient updated to hospital patient

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Page 30 – paragraph added on dealing with inappropriate claimant behaviour

Page 32, 35, 39 – title amended

Page 32 – first paragraph amended to remove reference to DLA

Page 34 – first paragraph amended to remove reference to ESA

Page 34 – more observations added

Page 37 – specific reference to DLA removed and second question amended to be more generic

Page 38 – question 3 added to reflect other benefits

Page 40 – HPC updated to HCPC

Page 40 – addition of Training Support Manager

Page 40 – MCQ questions 1 and 6 amended to avoid ambiguity

Page 41 – Title updated to Service Delivery Lead

Outstanding issues and omissions

Updates to Standards incorporated

Issue control

Author: Medical Training & Development

Owner and approver: Clinical Director

Signature: Date:

Distribution:

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Contents

1. Why have I been given this module? 7

2. What terms are used to describe the problems associated with drug and alcohol use? 8

3. How commonly do problems with alcohol occur and what are the main effects? 12

Scale 12

Main Effects 14

4. How commonly do drug-related problems occur and what are the main effects? 18

Scale 18

Main effects 20

5. How do substance abuse problems relate to the work I do in Atos Healthcare? 22

6. How do we assess claimants with substance misuse problems?23

Documentary evidence 23

Observation 24

Interview 24

Mental State Assessment 25

Physical Examination 27

Completion of reports 28

Prognosis 29

7. What should I do if I am asked to see someone who is obviously drunk or intoxicated? 30

8. Case Studies – looking at different clinical presentations during benefit assessments 32

Case Study 1 32

Case Study 2 34

9. Case practice – reflection on different scenarios 35

Case Practice 1 35

Case Practice 2 37

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Case Practice 3 38

10. Conclusion 39

11. Multiple Choice Questions 40

Observation Form 41

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This module details the particular problems involved with claimants who have drug or alcohol problems.

The module discusses the subsequent assessments, opinion formulation and report writing for these

claimants.

1. Why have I been given this module?

This module is important to help HCPs offer appropriate advice during the assessment of claimants with drug and alcohol problems. HCPs will need knowledge of the subject and details about the ways in which claimants present. HCPs will also need a reliable method of recording their clinical examination findings.

It is recognised that some HCPs do not regard drug or alcohol misuse as a medical problem unless there is serious physical or psychological harm. However, such a view does not concur with the consensus of medical opinion and, as disability analysts, we see many problems that result from alcohol and drug misuse, causing damage in physical, psychological and social terms.

HCPs working for Atos Healthcare will frequently see claimants with drug and alcohol problems; and they will need to use their skills as Disability Analysts in the assessment of these claimants.

Towards the end of the module there are some case discussions. These are followed by three case presentations with questions about how you would proceed in different scenarios. These have been introduced to give you some practical guidance about your management of everyday situations.

The final section contains a Multiple Choice Questionnaire which you will have to complete and return to your Clinical Manager or your local Training Support Manager.

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2. What terms are used to describe the problems associated with drug and alcohol use?

‘Alcoholism’ and ‘alcoholic’ are terms commonly used to describe someone with an alcohol problem. The terms are somewhat misleading because they imply a single condition; the terms also tend to stigmatise that person1.

The words ‘alcohol problem’ indicate a level of consumption that can cause medical, psychological or social problems, or lead to dependence

Similarly, the terms ‘drug addict’ or ‘addict’ are poor terms to describe someone with a drug problem.

However, the terms ‘alcoholism’ and ‘drug addiction’ are in common use and will be encountered frequently.

Stigmatisation is common is people with drug and alcohol problems and leads to prejudice and discrimination. It may result in a delay in the individual seeking help and may put barriers into the road of recovery or reintegration. Stigma is widespread and affects both the individual with a drug/alcohol problem and their families. Stigma can only be avoided by a change in the attitude and an increase in awareness of the problems faced by people with alcohol and drug related problems by society in general.

Harmful use of drugs and alcohol is defined by the World Health Organisation as 'a pattern of psychoactive drug use that causes damage to health, either mental or physical.'

Alcoholism or drug addiction is then taken to be a form of altered (maladaptive) behaviour that can cause mental or physical disease.

The general term ‘substance-related disorders’1 refers to a wide range of conditions associated with the taking of drugs and includes:

Drug abuse

The side effects of medication

The toxic effects of drugs

A single definition for substance related disorders is neither possible nor desirable and therefore the classification and definitions used currently conform to those in the American Psychiatric Association’s diagnostic manual (DSM-5) and the tenth revision of the World Health Organisation’s ICD-10. These two classification systems use similar categories for substance related disorders but group them slightly differently.

1 We are grateful to Health and Wellbeing Directorate of DWP for the use of their material on

‘substance related disorders’, and acknowledge their assistance

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In DSM-5, the previous DSM-IV categories of substance abuse and substance dependence are now grouped into a single disorder – Substance Use Disorder. Different substances are addressed as a separate use disorder, such as alcohol use disorder, stimulant use disorder, etc. The severity ranges from mild to severe and includes criteria for intoxication, withdrawal, substance/medication induced disorders and unspecified substance use disorders.

In ICD-10, categories F10 - F19 refer to ‘Mental and behavioural disorders due to psychoactive substance use’

F10. – Mental and behavioural disorders due to use of alcohol F11. – Mental and behavioural disorders due to use of opioids F12. – Mental and behavioural disorders due to use of cannabinoids F13. – Mental and behavioural disorders due to use of sedative hypnotics F14. – Mental and behavioural disorders due to use of cocaine F15. – Mental and behavioural disorders due to use of other stimulants, including caffeine F16. – Mental and behavioural disorders due to use of hallucinogens F17. – Mental and behavioural disorders due to use of tobacco F18. – Mental and behavioural disorders due to use of volatile solvents F19. – Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances

The conditions are further subdivided to specify the clinical condition:

F1x.0 Acute intoxication F1x.1 Harmful use F1x.2 Dependence syndrome F1x.3 Withdrawal state F1x.4 Withdrawal state with delirium

F1x.5 Psychotic disorder F1x.6 Amnesic syndrome F1x.7 Residual and late-onset psychotic disorder F1x.8 Other mental and behavioural disorders F1x.9 Unspecified mental and behavioural disorder

Substance related disorders may be divided into two broad groups:

1. Substance use disorders

Further subdivided into:

a) Substance dependence; and

b) Substance abuse.

2. Substance induced disorders

Includes effects such as intoxication, withdrawal, anxiety and mood disorder.

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This can be shown diagrammatically:

Substance dependence and substance abuse create most of the physical (biological), psychological and social problems (bio-psychosocial effects).

People with alcohol problems are often referred to as heavy drinkers, problem drinkers or dependent drinkers2. These terms refer to forms of behaviour associated with ‘substance use disorders’.

Heavy drinking means either continuous or binge drinking, and can be used to include people who drink alcohol over the recommended daily limit.

Problem drinking is associated with domestic, occupational, legal, financial or medical problems that can all be overcome, or improved, by alcohol reduction.

A dependent drinker implies addiction to alcohol that may sometimes be

2 Paton A, ABC of Alcohol , BMJ, 2005

Physical and psychological injury results

from prolonged abuse and/or

dependence

Substance Related Disorders

Substance use disorders Substance induced disorders

Dependence Abuse Withdrawal Intoxication

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irreversible. Substance abuse is a maladaptive behaviour pattern manifest by repeated use of a substance despite recurrent and significant adverse effects on daily activities.

Substance dependence usually follows a repeating pattern of self-administration that results in tolerance, withdrawal and compulsive drug taking leading to clinically significant cognitive, behavioural and psychological symptoms.

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3. How commonly do problems with alcohol occur and what are the main effects?

Scale

Alcohol related disability is any mental or physical harm resulting from alcohol consumption. We may assess someone with alcohol related disability by looking to see whether there is uncontrolled drinking (abuse) and/or physical dependence on alcohol. This use of alcohol may result in:

Cognitive impairment/clouding of consciousness;

with

Physical disease;

and/or

Mental illness.

There is no truly safe level of alcohol consumption for anyone. Only an individual who is teetotal will be entirely free from risk2.

There were previously guidelines for the amount of alcohol consumed over the period of a week. However, a review of the effects of drinking3 concluded that it was more appropriate to set benchmarks for daily rather than weekly alcohol consumption, partly because of concerns about medical and social risks associated with single episodes of intoxication.

1 unit of alcohol in the UK is defined as 8g (10 ml) of pure ethanol.

Sensible limits of no more than 3-4 units of alcohol a day for men and 2-3 units a day for women are currently recommended by the Department of Health4.

A survey in 2007 showed that 92% of men and 89% of women had heard of measuring alcohol in units but were less knowledgeable about recommended maximum daily intake of alcohol5.

Since drinking surveys were first carried out in the 1970s, it has been assumed that one unit of alcohol (10ml) is contained in a half pint of beer, a glass of table wine, a small glass of fortified wine or a single measure of spirits.

2 Paton A, ABC of Alcohol , BMJ, 2005

3 Sensible drinking: the report of an inter-departmental group. Department of Health. 1995.

4 Safe. Sensible. Social. The next steps in the National Alcohol Strategy. Department of Health.2007.

5 Statistics on Alcohol England 2009. The NHS Information Centre. The Health and Social Care

Information Centre 2009.

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For many years, this was a reasonable approximation, but in recent years it has become apparent that the conversion of volumes of alcohol drunk into units needed updating: this is particularly the case for table wine, but also for strong beers, lagers and ciders - defined as having an ABV (alcohol by volume) greater than 6%6.

The following are now regarded as more accurate, based on the increasing strength of alcoholic drinks (ABV):

Wine:

A small glass (125ml) = 1.5 units

A standard glass (175ml) = 2 units

A large glass (250ml) = 3 units

Beer:

Half pint of strong beer = 2 units (rather than 1.5)7

Pint of lower strength beer/lager/cider = 2 units

Pint of higher strength beer/lager/cider = 3 units

Bottle of beer/lager/cider (330 ml) = 1.5 units

Can of beer/lager/cider (440 ml) = 2 units

The abuse of alcohol is a major problem in our society

The UK has a serious drink problem and 3 million people are mildly dependant on alcohol - perhaps 10% of these are likely to become addicted to alcohol unless they recognise the problem and cut down8.

These terms were described earlier as:

Heavy drinking means either continuous or binge drinking.

Problem drinking is associated with domestic, occupational, legal, financial, or medical problems that can all be overcome, or improved, by alcohol reduction.

A dependent drinker implies addiction to alcohol that may sometimes be

6 Drinking: adults’ behaviour and knowledge in 2007, A report on research using the National Statistics

Omnibus Survey produced on behalf of the Information Centre for health and social care





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irreversible. Statistics for 2011 showed that 66% of men and 54% of women (aged 16 and over) reported drinking an alcoholic drink on at least one day in the week. There has been a long-term downward trend in the proportion of adults who reported drinking and in 1998, 75% of men and 59% of women had reported drinking on at least one day in the week. About 39% of men and 27% of women drank above the recommended levels on at least one day a week. 22% of men and 13% of women drank more than twice the recommended amount at least once a week. 9

In 2009, over a third of men (37%) drank over 4 units of alcohol on at least one day a week and 29% of women drank more than 3 units on at least one day a week. A fifth of men (20%) drank over 8 units and 13% of women drank over 6 units in one day10.

Statistics available for 2007 showed that 33% of men and 16% of women were classified as ‘hazardous’ drinkers (defined as a pattern of drinking that brings about the risk of physical or psychological harm). This includes 6% of men and 2% of women estimated to be ‘harmful’ drinkers (the most serious form of hazardous drinking, consisting of a pattern of drinking that is likely to lead to physical or psychological harm). About 9% of men and 4% of women showed signs of alcohol dependence11.

The figures suggest that although the proportion of people who are drinking has decreased, the people who are actually drinking are drinking more. This is further confirmed by statistics which showed an 11% increase in alcohol related hospital admissions from 2010 to 2011.

Alcohol misuse is found in a significant proportion of the homeless, in whom unemployment, loss of family, and financial difficulties caused by drinking, all contribute to a degrading existence. A similar consideration applies to drug misuse, either on its own or in combination with alcohol misuse.

Main Effects

Alcohol use can lead to physical, psychological, and social problems.

When assessing claimants with alcohol problems, it will almost always be necessary

9 Statistics on Alcohol: England 2013, The Health and Social Care Information Centre 2013.

10

Statistics on Alcohol England 2009. The NHS Information Centre. The Health and Social Care


11

Statistics on Alcohol England 2009. The NHS Information Centre. The Health and Social Care


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to carry out physical and mental health assessments.

Physical problems involve many body systems, with the best known being the development of cirrhosis. The development of cirrhosis is often an indicator of alcohol misuse. Cirrhosis, hypertension and some cancers show a dose response relationship between alcohol and morbidity, i.e. the greater the amount drunk the greater the harm. However, there is some evidence that alcohol intake of 1-2 units daily may actually protect against coronary artery disease.

There are many other physical problems that can be associated with alcohol use. These are shown in the table below.

System Physical Problem

Gastrointestinal system Cirrhosis Oesophageal varices Peptic Ulcer Gastritis Hepatitis Pancreatitis Carcinoma of oesophagus Carcinoma of oropharynx

Central nervous system Convulsions Brain damage Peripheral neuropathy Cardiovascular system Alcoholic cardiomyopathy

Cardiac arrhythmias Respiratory system Pneumonia Tuberculosis Musculoskeletal system Haemopoiesis Metabolic

Myopathy Osteoporosis Osteomalacia Macrocytosis Thrombocytopenia Leucopenia Malnutrition

Obesity Vitamin deficiencies

Psychological conditions associated with alcohol use include depression (with a high suicide risk), anxiety and psychotic illness including Korsakoff’s psychosis. Cognitive impairment is also seen. There may also be a loss of personality and self-regard, with abnormal behaviour and abnormal lifestyle to the point of extreme

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poverty and neglect.

Social problems associated with alcohol use include family and marital problems, employment difficulties and involvement in accidents and crime. Accidents occur at work, at home and on the road. Involvement in crime can include being found drunk and disorderly, offences involving breach of the peace and drink-driving offences.

In the work setting, people with alcohol-related problems have a high level of absenteeism. They also have accidents and injuries, causing breakages at work and demoralising colleagues. Stealing may occur to support the purchase of alcohol12.

The ‘excessive’ consumption of alcohol does not, by itself, indicate mental or physical illness. However, physical, psychological and social problems can develop as outlined above.

Sometimes, the excessive alcohol consumption may lead to severe medical problems. These may be:

Mental disablement with the claimant suffering from a severe mental illness;

or

Physical disablement of a marked degree.

A severe mental disablement may be shown by:

Alcohol dependency which adversely affects a person's behaviour, restricts social functioning and requires treatment in a detoxification unit or residential rehabilitation unit

The presence of associated psychiatric disorder, which may include psychotic illness

Alcohol abuse which has led to loss of insight due to cognitive impairment

Alcohol abuse with loss of personality and self regard leading to abnormal behaviour and lifestyle to the point of extreme poverty and neglect

Failure of memory, deterioration of personality, loss of intellectual ability resulting from cortical atrophy

Physical disablement of a marked degree may be shown by:

Physical effects of alcohol withdrawal, e.g. convulsions, delirium tremens

Disorders resulting from malnutrition

The presence of a toxic or nutritional condition affecting the central nervous system

Presence of cerebellar degeneration causing ataxia of gait, which may be combined with peripheral neuropathy

Those cases with an associated stroke, myopathy or cardiomyopathy

Alcoholic polyneuropathy: a sub acute, symmetrical, painful sensorimotor

12

Cox R A F, Edwards F C, Palmer K, Fitness for work, Oxford University Press,2000

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neuropathy affecting the motor nerves with distal weakness and wasting, sometimes with muscle tenderness. There may be a burning sensation in the feet, patchy loss of pain sensation and absent ankle jerks

Alcoholic myopathy: acute myopathy produces muscle pain and tenderness; sub acute myopathy presents with painless symmetrical proximal muscle weakness

These features may not be obvious initially, and may only become evident after formal examination of the mental state or after appropriate physical examination.

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4. How commonly do drug-related problems occur and what are the main effects?

Scale

The scale of the drug problem13 is very difficult to estimate

There are two main classifications used to describe drugs that are misused. The Misuse of Drugs Act categorises substances into three classes: A, B and C with decreasing penalties for possession, use and distribution. From a clinical perspective a descriptive classification that divides substances into four main categories - opioids, sedative/hypnotics, stimulants and hallucinogens - is probably more useful.

The substances most commonly encountered in disability medicine are:

1. Opioids, e.g. heroin and methadone

2. Sedatives and hypnotics, e.g. alcohol

3. Stimulants, e.g. cocaine

4. Hallucinogens, e.g. cannabis

There is no truly ‘safe’ involvement with the use of any drug, including the abuse of prescribed medication. The nature of the activity, the poor contact with statutory services and fear of detection all mean that data on the scale of usage is difficult to obtain.

The prevalence of substance use is inherently difficult to measure partly because of its illicit nature, but also because of the unique behaviour patterns of users.

Whether an individual will take a particular drug will depend on its availability, cost, legal status, alleged effects and form or preparation.

In England and Wales, in 2012/2013, 8.2% of adults had used one or more illicit drug within the last year, compared with 8.9% in 2011/2012. Young adults (those aged 16 to 24) were more likely to have used drugs in the last year than older adults. However, the proportion of adults aged 16 to 24 taking any drug in the last year was 16.3%, down from 19.3% in 2011/12. 14

In England and Wales, in 2009/10, 8.6% of adults had used one or more illicit drug within the last year, compared with 10.1% in 2008/09. Over the longer term this shows an overall decrease from 11.1% in 1996.

In 2012/2013, 2.6% of adults had taken a Class A drug during the last year, compared to 3.1% in 2009/10, and 3.7% in 2008/09.

13

In this description ‘drug’ refers to a substance that is ‘misused’ 14

Drug Misuse: Findings from the 2012 to 2013 Crime survey for England and Wales

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Consistent with previous findings, cannabis is the type of drug most likely to be used by adults; 6.4 % of 16-59 year olds used cannabis in the last year in 2012/2013, compared with 6.6% in 2009/10 and 7.9% in 2008/09. In all age groups cannabis is the most common (and often the only) illicit substance although the use of amphetamines, LSD and ecstasy (methylene dioxymethamphetamine – MDMA) is now fairly widespread, especially as ‘dance drugs’ at clubs and raves. The use of cocaine, including ‘crack’ has also increased over the past ten years while heroin abuse, although involving less than 1% of people, has now spread to rural areas.

Cannabis, often referred to as marijuana, pot, hash, hashish, weed or grass, is a mood-altering drug, often giving rise to feelings of relaxation and increased appreciation of sensory experiences. Its usage is widespread in the UK. Cannabis is attractive because of its compact packaging, its rapid onset of action and its easy availability. In 2009 it was reclassified from Class C to Class B.

Cocaine, particularly as ’crack’, is a growing problem in the UK. Cocaine acts on the central nervous system as a stimulant increasing alertness, delaying sleep and diminishing fatigue. It is commonly administered by inhaling or sniffing, and because of this, it is often seen as a convenient drug to take.

The intravenous injection of drugs, such as heroin, is a problem in a smaller core of the population. Heroin is an opiate drug that reduces sensitivity and emotional reaction. A major risk for people injecting drugs is the risk of becoming infected with the human immunodeficiency virus (HIV) and later developing acquired immune deficiency syndrome (AIDS). Intravenous injections can also lead to the development of hepatitis B, hepatitis C and other non-A non-B viral hepatitis infections.

To try to avoid these problems of infection, there are schemes in operation designed to provide clean needles and syringes, to allow needle replacement and to avoid any needle sharing practices.

Hallucinogenic drugs, for example lysergic acid diethylamide (LSD), are a problem particularly among younger people. Hallucinogenic drugs cause perceptual disorders with hallucinations and delusions. Panic and paranoia can result in self-harm or harm to others15.

Designer drugs are a rapidly changing feature of the drug scene at street level. Ecstasy (E) is a mixture of a stimulant and hallucinogenic, and has recently been popular. Similarly, injectable drug habits change with price, availability and fashion.

Within the UK, there are major variations in the use of different drugs in certain communities. For example, people from certain cultural groups chew khat leaves as a habit that is as widespread and accepted in their culture as cigarette smoking. Khat chewing can be an apparently innocent habit, but some people develop psychotic phenomena.

15

Donaldson R J, Donaldson L J, Essential Public Health Medicine ,Kluwer Academic Publishers, 1993

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During 2008/9, there were 207,580 people in contact with structured drug treatment services. Opiates (including heroin) were the main type of drug for which people received treatment. The total number of deaths related to drug misuse in England and Wales was 1757 in 2011 compared to 1,738 in 2008, with 72% of these were male in 2011 compared to 78% in 20081617.

Main effects

Drug problems cause a variety of physical and mental symptoms depending upon the particular drug or drugs being used.

When we are assessing claimants with drug problems, symptoms such as nausea, malaise, constipation, sweating, stupor and co-ordination problems are frequent. Pinpoint pupils and ataxia may be revealed on examination together with other signs such as self-neglect, needle marks and facial or peri-oral rashes. Cannabis does not cause cerebellar dysfunction (slurred speech and ataxia) but does cause problems with peripheral vision and the sense of time18.

Psychological problems include irritability, confusion and personality change. There may be inappropriate affect, hallucinations and other psychotic features. Cannabis has deleterious effects on memory, attention span and perception. Cannabis impairs judgement, performance and immediate recall (whereas alcohol tends to affect the transfer process from short to long term memory stores). In the intoxicated state, cannabis, like alcohol, impairs short-term memory in proportion to the dose. However, moderate cannabis usage (but not alcohol) is associated with short-term memory deficits that persist for several weeks. Visual hallucinations and intrusion of memories can also occur with cannabis usage.

Social problems may include unexplained debts, criminal behaviour and family difficulties all associated with drug-seeking behaviour.

In the work setting, people with drug problems, like those with alcohol problems, have a high absenteeism rate, are involved in accidents and injuries and may be involved in stealing to support the drug habit12.

Harmful drug use or drug dependency may result in mental or physical harm to the claimant.

The use of drugs does not, by itself, indicate mental or physical illness. However, physical, psychological and social problems can develop as outlined above.

Like alcohol problems, sometimes the drug usage may lead to severe problems.

Again, these can be:

16

Statistics on Drug Misuse: England, 2009. The NHS Information Centre. The Health and Social Care

Centre. 2009.

17

Drug related deaths in the UK, Annual report 2012. National program on substance abuse deaths. 18

Cox R A F, Edwards F C, Palmer K, Fitness for work, Oxford University Press,2000

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Mental disablement with the claimant suffering from a severe mental illness; or

Physical disablement of a marked degree

Mental disablement may be shown by:

Psychotic disorder resulting from drug abuse. Such disorders are often short lived, unless drug abuse is a dual diagnosis with a separate mental health disorder

Drug dependency which adversely affects a person's behaviour, which restricts social functioning and requires treatment in a detoxification unit or residential rehabilitation unit

A separate depressive disorder

Concomitant abuse of alcohol of a degree demonstrating mental illness

Physical disablement may be shown by:

Neurotoxicity, cerebrovascular accident or other forms of central nervous system damage resulting from drug abuse

The presence of HIV-related disease

These features may only become evident after formal examination of the mental state, or after appropriate physical examination.

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5. How do substance abuse problems relate to the work I do in Atos Healthcare?

There is likely to be considerable local variation in the numbers of claimants seen with drug and alcohol problems.

Alcohol and drug problems can lead to physical, psychological and social problems

You will see claimants with these various problems during all aspects of your work for Atos Healthcare

In the context of clinical examinations carried out on claimants with drug and alcohol problems for the purpose of disability analysis, it will almost always be necessary to perform an assessment of

both physical and mental health

HCPs working in Atos Healthcare will need good background knowledge about the subject of drug and alcohol problems. You will need to look at the functional problems affecting any individual claimant. These problems can be varied, and can involve physical and/or mental health issues.

Physical problems can involve many body systems. The best known is, of course, the development of cirrhosis due to excess alcohol intake. Psychological problems can take many forms.

As HCPs, you will need to take a history from the claimants, observe them carefully and examine them appropriately. This will almost always involve mental and physical health assessments. You will then need to write detailed reports, answering the specific questions required by the Decision Maker, and giving opinions that take all the evidence into account and which are supported by written justification.

Throughout this process you will of course be acting as a skilled Disability Analyst. The recommended approach to adopt when assessing claimants who have drug and alcohol problems is discussed in more detail in the following section.

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6. How do we assess claimants with substance misuse problems?

As an HCP, you will initially need to assess whether the claimant is fit to be examined. People who are acutely intoxicated are unlikely to be able to give a reasonable account of themselves. In such circumstances, HCPs will have to decide whether they can advise the Decision Maker on the basis of judgement and inference with limited evidence from the claimant.

However, in the majority of cases you will be able to proceed with an assessment. You will need to assess the functional effects of drugs or alcohol on the claimant, utilising the principles of disability analysis. You will need to explore the four separate strands of evidence that are available to you:

Remember that the HCP’s opinions should be based on:

1. An assessment of the documentary evidence

2. Observation of the claimant

3. An interview in which effective questioning skills have been employed, eliciting details of the claimant’s activities of daily living

4. Examination of the physical state and/or the mental health of the claimant

You will also need to consider whether there are co-existing psychiatric or physical conditions present that impact on function and; if so, assess them accordingly.

Documentary evidence

You will need to peruse the available documentary evidence. Relevant information may be available to you in the form of:

Previous medical reports

Factual reports from doctors, e.g. the general practitioner or hospital doctor

Letters from healthcare professionals, e.g. community psychiatric nurse or psychologist

Remember:

Where there is a current history of alcohol or drug abuse, it will almost always be necessary to perform both

physical and mental health assessments.

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Letter from a social worker or a patient support group

Letters from friends or relatives

You will need to use your expertise and professional judgement to decide the relevant value of such information depending on its:

Nature

Source

The status of the person who gave it Such information can give valuable and credible information on the physical and mental state and degree of impact on daily living.

Observation

This gives valuable information on:

General appearance, gait, posture, balance

Eye contact

Involuntary movement, mannerisms

State of self-care, personal hygiene

Facial expression

General behaviour

Interview

The interview should focus on the clinical and functional effects of the substance usage on the individual. You must also seek to elicit whether there are any other psychiatric or physical conditions present that impact on function and, if so, address them as appropriate.

You should seek to obtain information concerning the current level of drug or alcohol usage. You will need to judge the best approach for this task, taking into account the freedom with which the claimant appears to be prepared to discuss this topic. For example, where you judge it appropriate, the questioning might be in the form of direct questions about this topic:

Do you smoke? What do you smoke? How much? For how long have you done so?

Do you drink? What do you drink? Roughly how much? For how long have you done so?

Do you use any non-prescribed drugs?

In other circumstances, this information will be better obtained by more open general questions in which the claimant details the circumstances of the drug or alcohol usage without direct questioning from the HCP.

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You will, of course, also need to explore how the claimant is affected in performing day to day activities. It is particularly important to ascertain how much they rely on social support from others.

As well as the specific information gathered from using appropriate interviewing skills you will be able to take account of:

The manner and response to the greeting, questions and comments

The ability to concentrate on the conversation

The ease of distraction

Any apparent disinterest with the interview

Thought processes and speed of response

Content and relevance of replies

Inappropriate or bizarre reactions

Establishing rapport

In some cases, it may prove difficult to develop reasonable rapport. Consequently, it is important to attempt to strike the right tone from the moment that the assessment commences. Asking the right questions in the right way for a particular claimant will enable you to obtain the most reliable information possible regarding the use of drugs and alcohol.

In order to maximise the information that can be obtained, you should make a special effort to ensure that:

There is good eye contact

You are sensitive to verbal and non verbal clues

You maintain positive body language

An empathic style is adopted

You are non-judgemental

Presenting symptoms/problems are clearly established

The assessment proceeds from open to closed questions if appropriate

Positive body language is an important factor. It can, for example, be helpful if you pause from writing/typing whilst the claimant is providing details of their level of substance usage, rather than appear to be engrossed in recording these details on the report.

Mental State Assessment

Remember the information needed:

Pre-morbid personality

Clinical history

Referral details

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Details of activities of daily living

Mental State examination

Mental health focus

In considering the mental health, it will prove relevant to enquire about:

Current level of drug or alcohol usage

Level of support received from others – medical and social

Current therapeutic intervention, if any

Daily activity - how is time occupied, how would they like it to be occupied?

Leisure activities - what is undertaken and how has this changed?

Ability to interact and communicate with others - what specific problems have there been?

Irritability - what factors cause irritability and what are the consequences?

Level of underlying anxiety - how does this manifest itself?

Fluctuation in mood - what is the daily/weekly pattern of the person's mood?

Concentration - what can the person do - read, watch TV, hold conversation?

Sleep problems

Problems that led to loss of work, if appropriate

Linking your findings to the mental state examination

Once you have assembled all the relevant information, you will be in a position to collate your findings in order to assess the claimant’s mental state. In the case of alcohol and drug problems, you will be concentrating on certain features, as follows:

Appearance How much attention does the claimant pay to their personal wellbeing and surroundings? Are there signs of self-neglect?

Behaviour Does the claimant engage in normal everyday activities? Is there any evidence of behavioural problems?

Speech Look for signs of intoxication or difficulty in communicating

Mood Look particularly for any underlying symptoms of depression or anxiety. Is the claimant’s mood withdrawn with an accompanying lack of drive? Or is there significant agitation?

Thought and perception

Is there evidence of organic disease or underlying psychotic illness?

Intellect and cognition

Is the claimant alert, fully orientated and able to process information? Can concentration be maintained? How is memory affected?

Addictive behaviour

What, and how much, substance is consumed? Over what time period has this pattern of behaviour been followed? Is there

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evidence of tolerance, withdrawal or compulsive usage?

Insight What understanding does the claimant have of the problem?

Coexisting mental health conditions and suicide or self-harm risk factors

It is vital to consider and assess any underlying depression/anxiety that may be present. You should remember that the risk of suicide is relatively high in people who abuse alcohol or drugs. Therefore, you should assess the claimant for excess risk factors including:

Intense feelings of hopelessness and worthlessness

Depression with marked sleep disturbance

Poor physical health

Living alone

Male > 45 or isolated younger male

Previous suicide attempts or self harm behaviour

Strong family history of mental illness, suicide or alcohol problem

Physical Examination

Where there are problems associated with alcohol or drug use, you should pay special attention to the following factors:

General physical features including:

General appearance including weight and weight distribution

State of self-care, personal hygiene

Smell of breath

Facial expression

Eye contact

Gait, posture, balance

Involuntary movement, mannerisms

Skin colour, markings, malar flush

Scarring, bruising, needle marks

Jaundice, naevi, palmar erythema Systems examination including:

Cardio-vascular and respiratory signs and examination (including blood pressure),

Gastro-intestinal signs and examination (including diet and nutritional status),

Nervous system including gait, posture, balance, involuntary movement and difficulties with sensation and balance problems.

For those claimants who are, or have recently been, injecting drugs, you will need to

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look for evidence of abscess, thrombophlebitis, or gangrene. Consider infectious status including Hepatitis B, Hepatitis C and other Non-A Non-B Hepatitis infections; as well as Human Immunodeficiency virus.

Completion of reports

You now need to consider all the evidence and give advice to the Decision Maker which is supported by written justification.

You should proceed to complete your report using the principles of disability analysis. In formulating your opinion, you will need to fully consider all the evidence that you have obtained from your perusal of the documentary evidence, observations, interview and examination of the physical and mental states.

Having taken all these factors into account you should be able to form an overall view of the level of functional impairment caused by the toxic physical or mental effects of the use of alcohol or drugs. These conclusions, taken in conjunction with your assessment of any functional effects that are caused by coexisting mental or physical conditions, will form the basis of your opinion to the Decision Maker.

In completing your report, ensure that you:

Address both the mental and physical aspects of the case, documenting the effects that drug or alcohol use is having on the claimant’s daily level of functioning

Address any coexisting mental health or physical condition

Record an overview of the claimant’s mental health – the mental state examination is crucial for this

Complete all specific questions posed in the report

Justify your opinion, drawing on all the evidence that you have assembled

Explain any apparent inconsistencies in the evidence

Support Group and ‘Treat as LCW’ criteria (ESA)

HCPs undertaking filework or performing assessments for the purposes of Employment Support Allowance (ESA) benefit claims need to consider whether claimants with severe mental health or severe physical function problems resulting from alcohol or drugs misuse meet criteria for advising entry into the Support Group.

They must also consider whether they meet criteria for advising ‘Treat as LCW’. In the Treat as LCW category relating to hospital patient status, ESA amendment regulations 2011 and 2012 allow for those who are having residential treatment for alcohol or drug rehabilitation to be considered as having LCW irrespective of whether the care is provided by a healthcare professional.

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Prognosis

In formulating advice on prognosis to the Decision Maker, you should consider the following:

Whether the claimant accepts that there is a problem

The degree of motivation for change, taking account of both medical and behavioural history

Whether the claimant is currently on stable treatment or maintenance

Previous attempts at rehabilitation, either in the community or in a residential setting

The latest evidence-based medicine available on the topic of functional rehabilitation for people with problems similar to those of the claimant

The therapeutic options usually undertaken and length of time that such treatments customarily occupy. In-patient treatment (or residential treatment in a non-healthcare led setting) including detoxification programmes, may be required but necessitates insight and personal motivation on the part of the claimant. It is also dependent on the availability of resources.

Any other indications that suggest a particularly good or poor functional outlook. A favourable prognosis would be suggested by a high level of motivation and strong community support.

Taking these factors into account, and using your knowledge and expertise, you need to consider what is the probability of the functional effect of the condition improving to a significant degree.

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7. What should I do if I am asked to see someone who is obviously drunk or intoxicated?

HCPs should be familiar with the current guidelines and procedures to follow when dealing with claimants who demonstrate inappropriate or aggressive behaviour. They should be aware of the Health and Safety polices and ensure they are familiar with various security measures, such as panic alarms in the Medical Examination Centres, or the use of Skyguard for Domiciliary visits.

HCPs may be asked to see claimants who are drunk or intoxicated. A claimant may arrive at an examination centre exhibiting abnormal behaviour, suggestive of intoxication as a result of alcohol or drug abuse.

Under these circumstances, the HCP should, if possible, be accompanied by the Medical Centre Adminstrator (MCA) throughout the assessment. The MCA should be prepared to leave the room to summon assistance at any time during the assessment.

Similarly, HCPs may visit claimants at home and find the claimant behaving in an unusual manner, suggestive of an intoxicated state.

In each case, the HCP needs to decide whether an adequate history and examination can be undertaken

The HCP will need to consider whether an adequate report can be completed, and importantly, must consider personal safety at all times.

The assessment should be terminated without completion if:

The behaviour of the claimant poses a threat to you or to other staff or claimants

There is persistent uncooperative behaviour by the claimant.

In this context the term ‘uncooperative behaviour’ should not be taken to refer solely to claimants who appear to be behaving in a deliberately obstructive manner. On some occasions, the claimant may not be able to properly understand the questions posed by the HCP. You will need to make a judgement as to whether the claimant is able to understand your questions sufficiently well. If they are too intoxicated to respond meaningfully, you should halt the assessment. Depending on the circumstances, you will then need to decide whether or not you have been able to glean sufficient evidence to complete a report for the Decision Maker. This point is illustrated in Case Study 1 (Section 8).

If the assessment has had to be curtailed in circumstances where you feel that you have insufficient evidence to draft a report for the Decision Maker, Atos Healthcare will normally offer a further appointment to the claimant for the purpose of completing the assessment.

In any benefit assessment work, if the assessment and reports cannot be completed then the HCP should consult an experienced practitioner, usually by ringing the

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Customer Service Desk. You will need to complete a full and detailed account of the claimant's behaviour, and give the reasons for terminating the assessment on the appropriate Unacceptable Claimant Behaviour Incident Report Form. If an MCA has been present during the interview, the MCA should countersign the record of events.

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8. Case Studies – looking at different clinical presentations during benefit assessments

Case Study 1

In my role as an HCP, I was asked to assess a claimant as a domiciliary visit for the purposes of a benefit claim.

I had arranged to see the claimant at 1pm. I arrived at the address on time and noticed the address was, in fact, a guesthouse. The woman who let me in said that she was the landlady, and that the person I had come to visit had a room on the first floor. She took me to the room. I knocked on the room door and was told to ‘go away’. The landlady opened the door and then left. I saw the claimant lying on the bed surrounded by lager cans – some full, some empty. He was dressed but rather unkempt, wearing dirty clothes and unshaven. He looked thin and unwell. He said that he did not want to be seen by me, saying it was time for him to go out.

Just then, his sister arrived. She said that she lived nearby and called in to see the claimant four or five times a week to check that he was managing. She told the claimant that he should answer my questions. He said he would try, and when I asked, confirmed that he wanted his sister to remain present. I tried to undertake an appropriate interview. I sat down and tried to look at him. I began to talk and ask questions. I asked him some specific questions to obtain necessary information in order to be able to complete the report as open style questions did not produce any relevant information, for example:

‘’Do you get out for a walk?”

“Do you go to the shops?”

“Do you cook your own meals?”

“What help does your sister give you about the flat?”

“Do you take any treatment?”

“Do you need reminding to take your tablets?”

He replied that he had no problems at all; he could do everything he wanted to do. I was able to write his comments down. He was in a great hurry and tried to leave.

He got up, staggered, and went downstairs, falling down the last 4 steps. He picked himself up, shouted to his friends and they all went out together.

His sister said that this was his regular pattern. He would probably now not be coming back till very much later and would probably be in a drunken state. She told me that his rent was “paid directly by Social Security”. He had a social worker who had applied for various benefits on his behalf. His sister told me that “other doctors had been to see him”, but he had been out or he had been too uncooperative to be seen.

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She told me that he had been like this for about 6 months, all the time he had been living at this address.

I offered to go back to see him again and get a fuller picture. His sister said I had been lucky to see him today and that he had said more to me than usual.

Although I had had very limited contact with the claimant, I was able to complete the report.

I was able to describe the claimant and make an assessment of his mental state. I had seen his living conditions. I had made general observations of him - he looked unwell, he smelt of alcohol, he appeared to have lost weight, and his self-care was poor.

Although I had not been able to examine him physically, I had observed him generally, seen him walking and seen him fall downstairs.

I had some history from his sister, who had confirmed that this was his usual state.

Although this information is limited, there appeared to be sufficient information to complete the report for the Decision Maker.

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Case Study 2

I saw a woman at a Medical Examination Centre. She was claiming benefits due to alcohol problems. The stated cause of incapacity was ‘Alcoholic’, but I had no further information.

She arrived at the centre for an early afternoon appointment. She arrived slightly early and sat waiting in the waiting room acting in an appropriate manner.

I called her in to the consulting room, and I noted that she walked normally to the room. She was well presented and looked tidy. She apologised for smelling of alcohol – she said that she had had to have a drink to steady her nerves. She had driven to the centre.

She gave a good account of herself. She said that she started to drink a lot when her children grew up and left home; at the same time, her husband was often away on business. She didn’t feel she had a drink problem, but lost her job as a secretary because of a lot of sickness and repeated accidents at work. It was then that she realised just how much she was drinking, because she could not afford the alcohol and missed it. She had even thought of just taking bottles from the supermarket, but had been afraid she would be caught.

She then saw her GP and was referred to a local drug and alcohol unit. She went to a few AA meetings. However, she couldn’t do without alcohol. She felt guilty about going to the AA meetings where everyone else was ‘so good’. She said she still liked to drink but managed to limit this to the evenings by constantly drinking coffee and tea throughout the daytime.

She said she had no physical problems and took no medication.

I was able to complete the assessment, concentrating on her mental health, and was able to make a full assessment of her mental state. She had lost her job probably as a result of alcohol problems and she still had a craving for alcohol. She was, however, functioning normally throughout the daytime.

Her appearance and behaviour were appropriate. Her speech and mood were normal. She had no problems with thoughts or perceptions and her intellect and cognition appeared normal. She displayed some evidence of addictive behaviour and had a somewhat limited insight.

Observations did not suggest any evidence of physical problems.

I was able to complete the required report.

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9. Case practice – reflection on different scenarios

We are now going to present you with some case scenarios. Try to imagine that you are actually dealing with these claimants, and answer the questions posed. Think carefully about how you would really respond.

Compare your answers with the suggested responses, which are given after each case scenario.

Case Practice 1

You are assessing claimants for benefit in a Medical Examination Centre. You go to the waiting room to call your next claimant, Mr M, who rises when you call his name, but staggers slightly on standing up and is a little unsteady as he makes his way along the corridor. He smells of stale alcohol, his face is flushed and you note that his conjunctivae are rather suffused. When in due course you begin the interview however, his speech is quite distinct and in responding to your questioning he appears, at least at first, to give a reasonable account of himself. You are able to elicit a reasonable, if slightly muddled medical history.

The diagnosis provided by his general practitioner is:

1. Nervous debility

2. Osteoarthritis both knees

Normally you would now proceed to elicit a description of his average daily activities. Before embarking on further assessment, reflect on how you would proceed. Consider the following points:

1. Should you continue with the assessment?

2. Describe the steps that you would take in order to achieve a successful outcome to the assessment?

3. What particular features would you wish to concentrate upon during your clinical examination of the claimant?

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Suggested response

This scenario is not all that uncommon.

1. An assessment should be terminated without completion if either:

a. The behaviour of the claimant poses a threat to you or to other staff or claimants; or

b. The claimant’s behaviour is persistently uncooperative

Given the outline facts described above, it seems unlikely that either of these criteria apply in this case.

2. You should continue with the assessment, if possible accompanied by the MCA throughout the assessment. You should remain alert to the possibility that the situation might deteriorate, in which case you should be ready to abandon the assessment for it to be rescheduled at a later date. However, by maintaining an empathetic, non-judgemental approach during the interview, you can minimise the risk of a confrontational situation developing. You should pay due attention to the affects of the unrelated physical problem (Osteoarthritis of the knees in this case), which may often be seen by the claimant as their major source of difficulty. You should attempt to maintain positive body language and good eye contact. You should attempt to provide an explanation of the actions that you are taking as you proceed.

3. The nature of your clinical examination will depend to a certain extent on the report involved: this might be ESA, DLA, IIDB, SPVA or any other assessment. Detailed discussion of specific benefit requirements or the requirements of other reports is outside the scope of this generic module, but where disability in a general sense is being assessed your physical examination should include a search for evidence of chronic alcoholism and its sequelae (liver disease, brain damage, etc.) In this case, in view of the stated diagnosis of Osteoarthritis of the knees, a relevant musculoskeletal examination is appropriate. With regard to the mental state examination, you will wish to assess the extent of his addictive behaviour and look for any coexisting mental health problems. You have already made observations regarding his appearance, behaviour and speech. For the rest of the interview, you will want to place particular emphasis on an assessment of intellect, cognition, mood and insight.

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Case Practice 2

Ms A, who is aged 20 lives with her mother, Mrs A. You are performing a domiciliary visit in connection with a benefit claim. It is said that Ms A is addicted to Temazepam and is determined to give it up, but on previous attempts to abandon the habit she began clandestinely buying further supplies despite her mother’s vigilance.

In her application Ms A claims that she requires constant supervision.

She is a thin, pale, young woman who says very little and when addressed directly she refers to her mother for help in making a reply. She sits and stares abstractedly out of the window during much of the conversation.

Mrs A says that the only means of helping her daughter to overcome her addiction is to watch over her at all times.

1. What particular mental health features would you look for during the assessment?

2. Considering the benefits you are trained in, what advice would you give the Decision Maker in terms of Ms A’s safety awareness/need for supervision?

Suggested response

1. You would wish to reassure yourself that Ms A was not suffering from any coexisting mental health/function condition which might itself give rise to problems with safety awareness and requirement of supervision. A careful history should be taken, and any instances of potentially dangerous behaviour should be sought.

2. Withdrawal symptoms from the gradual reduction of benzodiazepines should be minimal if undertaken gradually, with medical advice and help. In the absence of any co-existing mental health/ function condition, safety awareness would normally be maintained and the need for supervision should not normally arise.

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Case Practice 3

You are examining Mr L, who is 42, in connection with a benefit claim following an accident at work 6 months ago in which he fell from the back of his lorry, injuring his right elbow and wrist and left knee. While assessing extension, then pronation and supination of his elbows you notice a fairly marked tremor of the hands. You recall that on showing him into the room you caught a whiff of alcohol from his breath. The time is 11.30 am.

A swift, diplomatic exploration of his average day reveals that he goes to the pub every lunchtime “to play dominoes,” and most evenings. He says he does not drink much; he “knows when he’s had enough”. He can barely control the pen when signing his statement – he laughs apologetically and says that his nerves are bad since the accident. You notice his eyes and you are suspicious that he might be clinically jaundiced.

1. What, if any, further steps should you take?

2. How do your findings impinge upon your advice to the Decision Maker?

Suggested response

1. A brief, diplomatic and factual discussion of the actual amount of alcohol consumed might be the best course of action here. Unless he had already consulted his GP about his alcohol intake, you should advise him to see his doctor and follow the unexpected findings procedure to alert the GP to the issue.

2. Registered Medical Practitioners who assess claimants for Industrial Injuries Disablement Benefit (IIDB) need to explore what, if any, impact this condition (his hand tremor) has on upper limb function and determine whether it started before or after the accident, i.e. whether it is an “O-pre” or “O-post” condition.

3. For other benefits, you would need to determine the overall level of function which is present, taking into account his physical and mental health problems, with appropriate physical and mental state examination, in order to be able to give appropriate advice to the decision maker.

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10. Conclusion

Do you have any comments about this module?

If so, please complete and return the observation sheet. We do value feedback.

In any event, please ensure that you complete the MCQ and send to your Clinical Manager at your Medical Services Centre as soon as possible.

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11. Multiple Choice Questions

Please assist the evaluation of the training and guidance material by returning this page with the questions shown below completed. True False

1. A unit of alcohol is approximately equivalent to ½ pint of lower strength beer

2. You should never ask about suicide risk, because a claimant might then think of self-harm

3. You can ignore the Mental health of claimants with a drug problem if they have major physical problems

4. Drug and alcohol problems are not common in our work

5. Alcoholism is the best term for someone with alcohol problems

6. When you perform a benefit assessment of a claimant with a drug problem, you are acting as a Disability Analyst

7. You should not assess a claimant who has had a drink just before the assessment

8. Grass, pot, hash, and hashish are all terms for cannabis

9. Cannabis use commonly leads on to other drug use

10. Alcohol problems can lead to malnutrition or obesity

NAME(Please Print)

SIGNATURE:

GMC/NMC/HCPC Number:

DATE:

BASE (MSC)

On completion please return to the Clinical Manager at your local Medical Services Centre or your local Training Support Manager

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Observation Form

Please photocopy this page and use it for any comments and observations on this document, its contents, or layout, or your experience of using it. If you are aware of other standards to which this document should refer, or a better standard, you are requested to indicate this on the form. Your comments will be taken into account at the next scheduled review.

Name of sender: ________________________ Date: _____________ Location and telephone number:____________________________________

Please return this form to: XXXXXXXXXXX Service Delivery Lead

Atos Healthcare 3300 Solihull Parkway Birmingham Business Park Birmingham

B37 7YQ

Documents

The Assessment of Claimants with Drug or Alcohol … Assessment of Claimants with Drug or ... The Assessment of Claimants with Drug or Alcohol ... Mental and behavioural disorders