Drug and Alcohol Awareness

This course offers an introduction to the effects of drug and alcohol on mental health. It considers why individuals might choose to use substances and discusses how assessment and treatment is delivered by the North London Forensic Service.

Defining Dual Diagnosis

What do we mean by Dual Diagnosis

The relationship between drug and alcohol use and mental illness is complex. The term 'dual diagnosis' is often used to describe this, although it is recognised that it does not fully capture all of an individual’s needs.

Examples of people with dual diagnosis (a combination of mental health problems and substance use) could include; A dependent drinker who experiences increasing anxiety. An individual with Schizophrenia who uses cannabis on a daily basis to 'help with voices', an individual with Bipolar Disorder, whose occasional binge drinking and experimental use of drugs destabilises their mental health or a recreational user of 'dance drugs' who has begun to struggle with low mood after weekend use.

What does Dual Diagnosis mean?

  • A term used for someone who has multiple difficulties
  • A term used to describe combined mental health problems and substance use
  • A disagreement between a service user and their doctor about diagnosis
Select one of the options below

Why Focus on Dual Diagnosis

Why we are interested in Dual Diagnosis

In 2010/2011, there were 6,640 admissions to hospital with a primary diagnosis of a drug-related mental health and behavioural disorder. A 14.3 per cent increase on the previous year (2009/10). Drug and alcohol use in high for individuals with mental illness and is associated with poor treatment compliance, longer admission and more frequent admissions to hospital.

Drugs misuse among adults (16-59 years), in England and Wales, has increased from 30.5 per cent in 1996 to 36.3 per cent in 2010/11 (2). Research has shown that drug and alcohol use can be associated with an increased risk of offending, especially violent and acquisitive crimes.

On the whole drug use is down from 3.3m in 2005 to 2.9m in 2011, with a significant drop in injecting, heroin and crack use (Drug Treatment 2012; Progress Made Challenges Ahead, NTA).

The consequences of drug and alcohol use for mentally disordered offenders can be as follows;

Drug and alcohol use can be associated with an increased risk of.

Drug use is  in people with a mental health diagnosis.

Drug and alcohol use is associated with  treatment compliance and  to hospital.


Understanding why people use Substances

Why people use drugs or alcohol

Some researchers believe that people with mental illness can start using substances to relieve symptoms of their illness, for example using cannabis to reduce stress or block out voices or alcohol to aid sleep -  this is called The Self-Medication Hypothesis.

Some researchers believe there are a number of factors that put people with mental illness at greater risk of using drugs or alcohol. these can include; social isolation, poor interpersonal skills, poor cognitive skills, poor education, poverty, lack of adult roles and responsibilities, association with drug subcultures and availability of illicit drugs - this is called The Multiple Risk Factor Model

Finally the Super-Sensitivity Model says that sensitivity  to psychoactive substances (increased vulnerability) may cause those with severe mental illness to experience negative consequences from using relatively small amounts.

What is the self-medication hypothesis?

  • People with mental illness have more underlying risk factors that increase the risk of using drugs or alcohol.
  • Drugs or alcohol are used to help relieve symptoms
Select the correct response

Understanding the Effects of Substances

Stimulant Drugs

Stimulant drugs speed up the body's processes, temporarily increasing alertness and energy. They can elevate the mood, producing feelings of excitement and happiness and can give the user an adrenaline rush often followed by a crash.

The drugs that fall into this category include cocaine, nicotine, caffeine, khat and amphetamines.

The short-term effects of stimulants can include exhaustion, apathy and depression. Longer term use can lead to feelings of paranoia, restlessness and anxiety. High doses can also result in dangerously high body temperatures and an irregular heartbeat.

Which of these are stimulants

  • Cocaine
  • Heroin
  • Khat
  • Amphetamine
  • Alcohol

Depressant Drugs

Depressant drugs depress the central nervous system and can reduce pain sensations. Depressants can mimic symptoms of depression when used excessively and it is easy overdose. There is also a risk of becoming dependent and experiencing withdrawal symptoms

Alcohol is the most frequently used legal depressant. Other depressants include solvents, GHB, barbiturates, and tranquilizers, e.g. diazepam and zopiclone.

Which of these are depressant drugs

  • Alcohol
  • PCP
  • Diazepam
  • Zopiclone
  • MDMA

Opioid Drugs

Opiod drugs have a powerful pain killing effect and can be higly addictive. They can include substances availabel on prescription such as codeine, methadone, morphine and tramadol.

Heroin is an example of the most widely used illegal depressant.

Which of these are opioids

  • Heroin
  • Cocaine
  • Codeine
  • Morphine
  • Methamphetamine


Within the category of hallucinogens substances may be divided acording to three main properties, making them; empathogens, psychedelics or dissociatives.

Hallucinogens alter perceptions and are sometimes known as mind-altering drugs. The most commonly used hallucinogens are Ecstasy, LSD and Ketamine.  These drugs can cause intense sensations, paranoia, delusions, and hallucinations and impair judgement and reasoning

Examples of Empathogens, Psychedelics and Dissociatives include

  • Ecstasy
  • Temazepam
  • Ketamine
  • Meow-Meow
  • Cocaine
  • LSD
  • PCP

Cannabis and Synthetic Cannabis (Spice)


Cannabis is the most commonly used illegal drug in the UK. Pleasant effects can include a feeling of relaxation, happiness, sleepiness and having music and colours seem intense.

However around 1 in 10 cannabis users have unpleasant experiences, including; confusion, hallucinations, anxiety and paranoia. Long term use can also have a depressant effect, reducing motivation. There is a growing body of evidence which suggests there is an increased risk of developing psychosis if cannabis is used in early teenage years.

The heavier the use, the higher the risk of developing mental illness, especially when more potent forms such as ‘skunk’, with higher levels of THC (tetrahydrocannabinol), the psychoactive ingredient in cannabis are used

Synthetic Cannabis is plant material which has been sprayed with synthetic cannabinoid receptor agonists. This produces a cannabis like effect when smoked but can be far stronger (up to 10x), ranging from pleasant relaxation to extreme agitation and paranoia.  Spice and more recently Black Mamba are now Class B drugs.            

Approaches to Assessment


In the NLFS we go beyond only using urine drug screens in assessing an individual's relationship with drugs or alcohol and their progress through the service group program.

We will also assess someone's motivation to change and engage in treatment, their stage of change, beliefs about substance use, their knowledge of the impact on physical and mental health and the coping strategies they have at their disposal.

What would be useful to assess in relation to drug or alcohol use in a forensic unit?

  • Motivation to change
  • Cravings
  • Coping stratgies
  • Beliefs about substances
  • Dependence and tolerance
  • Confidence in ability to change

Treatment Options in the NLFS

Treatment Program

The NLFS Drug & Alcohol Treatment Program is a three- stage integrated group & individual program, facilitated by members of the MDT.

Stage One comprises a ten-week psycho-educational group. It is linked to the engagement and building motivation phases of the C-BIT model and recognises that service users may not be ready to address their substance misuse difficulties.

Stage Two of the program is aimed at service users who wish to make changes in their substance use. It links to the negotiating behaviour change and early relapse prevention phases of the C-BIT model. Motivational Interviewing (Miller & Rollnick 2002) and cognitive behavioural techniques are used to help service users acquire the skills needed to support their decision to change.

Stage Three of the program links to the relapse prevention/relapse management phase of the C-BIT model and acknowledges that service users may face situations where they are exposed to, or offered, drugs or alcohol.

Untitled fill in the blanks question

The are  Stages in the NLFS drug and alcohol treatment program?