Transcript Document

Attending to alcohol and drug
misuse in the mental health sector:
should it be routine practice ?
David Newcombe
School of Population Health
Faculty of Medical and Health Sciences
University of Auckland
Nursing Education Forum, Wellington,
12 & 13 November 2009
Introduction/aims
• My personal journey
• Working in the addiction
sector
• University of Auckland –
training - combining
practice with theory
• An insight into relevant
research
• Moved to Aus when
13 years old
• Lived and worked in
many places in Aus
–
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Tasmania
Outback NT
Queensland
South Australia
• Moved to New
Zealand - 2006
My Personal Context - Early Career
• Nursing
• General training- Royal Adelaide Hospital
• Post Graduate Intensive Care & Burns
Nursing Course in England
– most notable event – met my wife
– and learnt lots as well !
• On return to OZ Worked in Melbourne and
Adelaide Burns units
• Awareness of link with A&D use/ mental
health issues and injury
• Impetus to learn more about human
behaviour
University training
• Flinders University of
South Australia Psychology training
• Worked as a
psychology lecturer
whilst undertaken post
graduate psychology
training
• PhD – Psycho
pharmacology
(addictions) at the
University of Adelaide
Working in the A&D sector
• New South Wales
– General A&D counsellor
– Manager MERIT team
– GP/Pharmacy liaison officer
• South Australia
– Regional Drug and Alcohol Services - Research
manager
– Worked in WHO Collaborating Centre for Alcohol and
Drug Treatment
New Zealand Beckons
• Academic position in the A & D area
• Post graduate co coordinator Alcohol and Drug
Studies
• Unique course – combines practice and theory
and builds on students existing professional
training
• Permits professionals from a variety of
professional backgrounds to gain knowledge
base in Addictions
Establishment of Academic
credentials - its taken time
1995 – First post-graduate course
1997 – First intake for PG Certificate (with
government funding)
1999 – First students take PG Diploma
2001 – Diversified courses on dual
diagnosis, gambling, biology etc.
2008 – Qualification established
Core courses
• Assessment & Intervention
with Addiction
– Full year course, clinical
skills based with supervision
and clinical observation
assessment
• Alcohol, Tobacco & Other
Drug Studies
– Half year course,
introduction to theory &
research
Elective courses
• Biology of Addiction
– Neurobiological basis of addiction and overview of
pharmacotherapies used to treat A&D dependence
• Theory and skills in counselling practice
– Overview of therapeutic approaches and skills
• Coexisting substance use and mental health
disorders
– I: Foundations - theory
– II: Interventions
Other courses continued
• Interventions for Lifestyle Change
– Work on design of projects relevant to area
• Gambling and Health
• Tobacco Control
• And able to choose from a wide variety of
culturally based and mental health papers
Current Qualification Layers
• Tiered framework allows students to
leave with the qualification that
matches their needs and abilities
– Post-graduate Certificate in Health Science
(Alcohol & Drug Studies)
– Post-graduate Diploma in Health Science
(Alcohol & Drug Studies)
– Masters in Health Science
• Research Masters and PhD
Relevant Research – practical
issues
• Attending to alcohol and drug misuse in the
mental health sector: should it be routine
practice ?
• If it should be then how can mental health
practitioners detect alcohol and drug misuse
amongst consumers?
Relevant Research – practical
question
• There is a need for a universal screening tool that
has been validated for use with people who have
mental health issues
• For example: The AUDIT – alcohol – validated for
use amongst people with MH problems
• Linked to brief intervention
• Or facilitates referral to specialist centre
• But only screens for one substance
• Development of the ASSIST is promising
What is the ASSIST?
• Alcohol, Smoking & Substance Involvement
Screening Test
• 8 item questionnaire (paper & pen)
• Administration time ~5-10 minutes
• Developed for health care workers in primary
care settings
• Validated in a variety of cultures
• Designed to be linked to a Brief Intervention
What does the ASSIST do?
• Screens for risky substance use
• Alcohol, tobacco, cannabis, cocaine, amphetaminetype stimulants, sedatives, hallucinogens, inhalants,
opioids, ‘other drugs’
• Determines risk score for each substance
• Current use (last 3 months)
• Lifetime use
• Score provides an opportunity to start
discussion (Brief Intervention) with client
about their substance use
The ASSIST – an overview
• Questions asked for all substance groups
• Lifetime use
– Q1 Ever used
Which of the following have you ever used ?
The ASSIST – an overview
• Last 3 months – current use
– Q2 Frequency of use
In the past 3 months, how often have you used the substances
you mentioned?
– Q3 Desire to use [Dependence]
How often have you had a strong desire or urge to use ?
– Q4 Health, social, legal, financial problems
How often has your use of (first drug etc.) led to health, social,
legal, or financial?
– Q5 Failure to fulfil role obligations
How often have you failed to do what was normally expected of
you because of your use of (first drug, second drug, etc ?)
The ASSIST
• Lifetime use
– Q6 Concern by others
Has a friend of relative or anyone else ever expressed
concern about your use of (first drug etc.)?
– Q7 Failed attempts to control use
[Dependence]
Have you ever tried to control, cut down or stop using
(first drug, etc) ?
– Q8 Injecting behaviour
Have you ever used any drug by injection (non-medical
use only)?
Levels of risk – target group
• Low risk (0-3)
• Abstinent or infrequent use, small amounts
• Moderate risk (4-26)
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Increased regularity of use
May be some problems – relationship, health, finance
Usual role obligations may not be fulfilled
Others may be concerned
Increase in risk taking behaviour
• High risk (27+)
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Weekly/daily use
Increased desire to use
More serious health & social problems, legal, occupational
Failed attempts to cut down
IV users
Components of Phase III trial
ASSIST score positive
Cannabis, Amphetamine, Cocaine, Opioids
Score 0-3:
Information
Score 4-26
Score 27+ or
frequent IV user:
Referral to
treatment
Group 1: Brief
Intervention
Group 2: Control
Delayed treatment
3-month follow-up:
ASSIST & feedback
3-month follow-up:
ASSIST & BI
Components of ASSIST BI
• F.R.A.M.E.S (Sanchez-Craig & Miller)
• Motivational Interviewing (Miller & Rollnick)
• 9 easy-to-follow steps
• 5 – 10 minutes long
• Purpose designed form to give feedback &
information to clients about their risk scores
• Bolstered with take away self-help guide
Total Illicit Substance
Involvement ASSIST Scores:
Control vs. BI
p < 0.001
F (1,160) = 14.7
power = 97%
Control n = 80
BI n = 82
Relevance to New Zealand /Aotearoa
context and mental health
• NZ has a drinking culture + many people use
other substances that can adversely affect
mental health (cannabis and amphetamines)
• Currently examining validity of ASSIST in Pacific
peoples – then plan to do the same in Maori.
• Recently validated in clients with first episode
psychosis (Hides et al, 2009, Addict Behav)
• Plan to examine feasibility and effectiveness of
using ASSIST linked to brief intervention in
clients with risk episode psychosis
Conclusions
• Attending to alcohol and drug misuse in the
mental health sector: should it be routine
practice ?
• What do you think?
• ASSIST looks promising
• Need to develop an appropriate intervention
that can lin with scores on the ASSIST