‘OST is an extremely valuable tool in the fight against drug addiction, and we are clear that the evidence base supports its part in our treatment system,’ says Adfam’s Medications in drug treatment: tackling the risks to children report (DDN, May, page 4). ‘However,’ it adds, ‘we also must recognise that the drugs used – especially methadone – are toxic, powerful and a clear danger to children when stored or used incorrectly by their parents and carers.’
Alongside interviews and a review of existing guidance and research, the report studies 20 serious case reviews from the last decade involving the ingestion of OST medication by children, and concludes that children’s safety is not being prioritised by treatment professionals. It calls for better training and improved national data collection, and says that far too little is even being learned from the findings of the serious case reviews themselves.
‘I do think that’s true,’ says Sue Bandcroft, who retired from her post as substance misuse manager for Bristol City Council last month and was involved in a serious case review in the city. ‘There’s always – and always should be – a lot of local learning, but that’s not always brought together and, because there’s no requirement to publish them in full, you often get reports that are very redacted, so it can be quite hard to find the messages.’
One of the consequences of this is an ongoing wide variation in practice across the country, says Birmingham GP and drug policy advocate Dr Judith Yates. ‘What we’re doing varies from place to place depending on whether we’ve had any of these tragedies in our area or not, and it seems a bit poor that we seem to be learning after each individual tragedy rather than having any central collation of it all. It needs to be national guidance, rather than waiting for some poor child to die and then learning from that, which is what we did here.’
A child whose family her practice was involved with died from an accidental ingestion in 2008, since which time ‘we’ve had safe storage boxes given to everybody,’ she says. ‘Some services around the country do that, and some don’t.’
A new study as part of the Keeping children safe at home project is now hoping to go some way to addressing these variations in practice. A multi-centre case control study of all children aged up to four who go to A&E as a result of poisoning – not just by OST – it aims to be largest ever to look at the modifiable risk factors for poisoning in young children, with its findings hopefully used to develop better prevention strategies.
As well as better data collection and improved analysis of serious case reviews, however, Adfam’s report is also calling for a ‘re-emphasis’ of the importance of safeguarding children when making decisions about OST in line with existing NICE guidance, and for improved training for drug workers, GPs, pharmacies, social workers and others to make sure they’re fully on top of child protection issues.
‘What looking at case reports clearly indicates again and again is just the importance of coordination and cooperation and communication between all the different agencies,’ says Yates. ‘So it’s not only drug workers who should be looking at where the methadone – and not just methadone, but all medication – is being stored in the house, but health visitors and everyone else. They look at stair gates and all the other hazards in the house, and they need to be particularly aware when parents are on particularly dangerous medication. When social workers make home visits they should be asking “where’s the medication? Show me”.’
In terms of challenging the parents they come into contact with, however, another finding from the serious case reviews studied in the document was that practitioners often ‘missed or minimised’ risk factors during the family’s contact with services, taking an ‘overly optimistic’ view of progress on the part of parents who were ‘able to manipulate or deceive’ services into believing they were making positive changes. The report calls for professionals to be more ‘robust’ in their work with families, with some cases described as ‘an accident waiting to happen’.
So, are drug workers open to manipulation by parents? ‘I think manipulation’s quite a hard word to use – it’s a very judgmental word,’ says Bandcroft. ‘Maybe “optimistic” about changes in clients. One of the things that we’ve certainly observed is that people would make plans with people, set them goals, and they wouldn’t reach them, so they’d make some more. Now that may be fine when you’re dealing with an individual adult drug user, but I think that when there’s children involved quite often we don’t ask ourselves the question “what’s the child’s everyday life experience of this?”
‘In the drugs world, the client’s needs and setting the client goals and being optimistic about their future has always been to the fore, but I think that very often we haven’t looked at people even in terms of couples or relationships,’ she continues. ‘In a partnership you need to make sure that if both are engaged in treatment then they have the same regimes, and that you also think about what your experience of it would be if you were the 18-month-old baby in this family.’
‘This is a constant message that we learn from all the safeguarding training – to have professional concern,’ says Yates. ‘It’s always difficult to make that judgment because you’re wanting people to do well and you’re trying to encourage people, and yet you have to keep your eyes open for the possibilities you could only know about if you’ve been properly trained. It’s an element of the training – to be aware that these cases happen.’
Sue Bandcroft did find her involvement with serious case reviews – she also chaired a case review sub-group on safeguarding children with substance-misusing parents – encouraging in some ways, however. ‘One of the positives that I found for the drugs world – which is actually in the recommendations of the Adfam report – is having somebody on the serious case review sub-groups, or however the local authority does it, who’s from a substance misuse background. I was a commissioner of services so I was able to know what services were available and what would be suitable.’
Disturbingly, however, though ingestion of OST medications by children is often the result of unsafe storage, there are also the ‘rare but real’ cases where methadone is deliberately given to children to pacify them, as had happened in five of the cases studied by the report. ‘In several more cases the practice was suspected, or how the child ingested the drugs is unclear,’ states the document. ‘It was clear from the serious case reviews that professionals working with these families had not accounted for this possibility, and this was mirrored by the interviewees in this research.’
‘That was another important message that came from the review I was involved in,’ says Bandcroft. ‘Nearly all drugs workers with someone on a methadone script talk about lockable cupboards, lockable boxes – a whole emphasis on ensuring the person has a locked box – but little is ever discussed about not giving the methadone to a child. You can have as many locked boxes as you like, but – to think the unthinkable – if somebody is actually giving it to a child it doesn’t matter that it’s locked away.’
Even among experienced practitioners who are fully aware of the dangers of children accessing OST drugs, the ‘practice of administering drugs to children was difficult to accept or address’ says the report. The answer, says Bandcroft, is for this to become part of a forceful generalised message, ‘rather than it looking as if you’re focusing on the individual. If there’s children involved then the message has to include “never give the methadone to a child”.’
In fact, Judith Yates’ local service in Birmingham has now done exactly that, as a direct result of Adfam’s findings. ‘When you read through any report like this you think “yes, I knew that” and “yes, we need to do that” and then you look for something which you’re not quite expecting, and I suppose the idea that methadone might be used as a soother or pacifier was a surprise to me,’ she says.
‘They found cases where there were signs that opiates had been given to the babies regularly, and one parent saying that it was sort of normal, accepted practice in their area. On the back of that we’ve changed our leaflet to include explicit warnings such as “never give your baby or child even a tiny amount of methadone or other opiate for any reason” and “babies and small children have died after tiny amounts of methadone have been given”.’
But if the key to addressing these disturbing issues is effective communication, then there’s also another message that has to be put over clearly, she believes. ‘Social workers and health visitors and everyone who isn’t a drug treatment worker needs to be firmly informed that parents being on opiate substitute treatment is the most important thing for the safekeeping of the children. If the parents are not on opiate substitute treatment, but are using illicit drugs, then that’s when the children are at most risk. Anything that threatens the ongoing engagement in treatment is increasing risk to the children.
‘Most social workers now accept that, but it’s ongoing education – particularly I think for health visitors and midwives sometimes – that OST is a good thing, not a bad thing,’ she says. ‘Clearly, the vast majority of parents on opiate substitution who’ve got children are taking their medication properly and safely. And keeping it away from their kids.’
Report available at www.adfam.org.uk