Transcript Drug and alcohol assessment

Jonathan Wood
Consultant in Substance Misuse
Outline
 Brief introduction
 Outline of major diagnoses
 Interactive session –Alcohol users
 Insight - Stages of change model
 ? Style of questioning for substance misuse
Why is it important to
psychiatrists?
 Substance Misuse is a mental illness
 People who are mentally ill abuse substances
 Substance Misuse is very common & costly
Alcohol harm -
Mental Health Population (COSMIC study)
Self-reported co-morbidity (year)
(n=282)
N
%
95% CI
Problem Drug Use
84
(29.8)
24.5 – 35.5
Drug Dependence
47
(16.7)
12.5 – 21.5
Alcohol Misuse
72
(25.5)
20.5 – 31.0
Drug use &/or Alcohol
124
(44.0)
38.1 – 49.9
Diagnostic Criteria
 By Substance:
F10 – Alcohol
F11 – Opioids
F12 – Cannabinoids
F13 – Sedatives
....
Diagnostic Criteria II
 By State:
.0 Acute Intoxication
.1 Harmful Use
.2 Dependence
.3 Withdrawal
.4 Withdrawal with delirium
...
Dependence syndrome 1
In the past year 3 or more of:
 (a) a strong desire or sense of compulsion to take alcohol;
 (b) difficulties in controlling alcohol-taking behaviour in
terms of its onset, termination, or levels of use;
 (c) a physiological withdrawal state when alcohol use has
ceased or been reduced, as evidenced by: the characteristic
withdrawal syndrome for alcohol; or use of the alcohol with
the intention of relieving or avoiding withdrawal
symptoms;
Dependence syndrome 2
 (d) evidence of tolerance, such that increased doses of alcohol
are required in order to achieve effects originally produced by
lower doses
 (e) progressive neglect of alternative pleasures or interests
because of alcohol use, increased amount of time necessary to
obtain or take alcohol or to recover from its effects;
 (f) persisting with alcohol use despite clear evidence of overtly
harmful consequences, such as harm to the liver through
excessive drinking; efforts should be made to determine that the
user was actually, or could be expected to be, aware of the nature
and extent of the harm.
Harmful use
 The diagnosis requires that actual damage should have been
caused to the mental or physical health of the user.
 Harmful patterns of use are often criticized by others and
frequently associated with adverse social consequences of
various kinds. The fact that a pattern of use or a particular
substance is disapproved of by another person or by the culture,
or may have led to socially negative consequences such as arrest
or marital arguments is not in itself evidence of harmful use.
 Acute intoxication, or “hangover” is not in itself sufficient
evidence of the damage to health required for coding harmful
use.
 Harmful use should not be diagnosed if dependence syndrome, a
psychotic disorder, or another specific form of drug- or alcoholrelated disorder is present.
Alcohol
 PC/HPC -
Units: trial
 How much is a unit?
 How many units in a pint of Stella?
 Can you pour a measure of spirits?
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Units of Alcohol
 A simple way to think about a amount of alcohol
 1 unit is 10ml alcohol
 For any drink you can work out the number of units:
 % alcohol x quantity in mls/1000
 E.g. bottle of wine 13%x 750/1000 = 9.75 Units
 One unit:
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Units in typical drinks
 Drinks come in difference sizes. If patients are unsure
you can help them work out the number of unit.
 Units in drinks:
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Alcohol
 P Psych H (& Past substance misuse history)
Alcohol
 PMH
Medical consequences of alcohol
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GI: liver, dyspepsia, diarrhoea, delayed healing of peptic ulcer, pancreatitis
Psychiatric: depression, suicide
Neurological: cognitive impairment, wernicke/korsakoff’s, neuropathy, stroke
CVS: hypertension, cardiomyopathy, arrhythmias
Nutritional: thiamine, folate, B12, malnutrition
Musculoskeletal: osteoporosis, myopathy
Immune: ↓T-cell function
Respiratory from associated smoking, TB
Renal: electrolyte disorders
Endocrine: cortisol, ↓testosterone, type 2 diabetes
Cancer: aerodigestive, breast, rectum
Fetal development: fetal alcohol syndrome
Alcohol
 FH
 Virginia twin study MZ 26% DZ 12% Heritability 40%
 Pers Hx / Social History
Alcohol
 Forensic
 PMP
Mental state
 A&B
 Speech
 Mood
 Thoughts
 Perception
 Cognition
 Insight
Physical Exam
 Intoxication
 Withdrawal
 Wernicke’s
 Alcoholic Hepatitis, cirrhosis
 Alcoholic Cardiomyopathy
 Alcoholic neuropathy
 GI disease
Blood tests for alcohol use
 For recent consumption
 Blood or breath alcohol
 For “chronic” consumption
 GGT, AST, ALT
 MCV
 (CDT)
Breathalyser
 Complicated by differences in measuring alcohol
 Usually Mass of alcohol per volume of blood or mass
of alcohol per mass of blood.
 UK = milligrams/decilitre (100 ml) of blood
 Drink driving limit = 80mg/dl blood
 May also come across breath alcohol drink driving
limit is 35mcg/100mls breath (conversion factor of
2100)
Blood Alcohol
 Detects recent drinking only
 ethanol metabolised at 10g/hour
 Breath levels correlate closely with blood
 In a person smelling of alcohol, BAC can
 confirm recent drinking
 suggest tolerance if high BAC, low impairment
 Urine alcohol: longer window of detection
GGT (Gamma glutamyltransferase)
 The most sensitive blood test that is widely available
 BUT only positive in 30% heavy drinkers in community
 Alcohol is commonest cause of elevation
 But up to 50% GGT elevation is for other reasons inc. obesity,
medications
 Half Life: 2 weeks
 Prognostic value, tool in monitoring
GGT II
 More likely to be elevated if:
 Male
 Obese
 Long drinking history
 Regular (cf episodic) drinker
 >30 years
Other markers
 Aminotransferases
AST:ALT >1.5 suggests alcohol
 MCV: slow return to normal
 t1/2 60 days
 Non-specific
(e.g. nutritional, drugs, liver disease)
 Increased even when folate/B12 normal
Stage of change & intervention
 Precontemplation (unaware/unready)

intervention unlikely to succeed, give information about risks
 Contemplation (aware/ambivalent)

offer advice &/or motivational work to move patient along
 Preparation (planning)

set date, make plans, be specific, anticipate difficulties
 Action (ready to go)

encourage, support, offer to follow-up
 Maintenance (keeping it up)

reinforce success, advise on managing slips/relapse prevention
Motivational style questioning
Definition
 Client-centred, directive method for enhancing
intrinsic motivation to change by exploring and
resolving ambivalence. (Miller & Rollnick.
Motivational interviewing. Preparing people for
change(2002)
 Express empathy, guides therapists to share with clients
their understanding of the clients' perspective.
 Develop discrepancy, guides therapists to help clients
appreciate the value of change by exploring the discrepancy
between how clients want their lives to be vs. how they
currently are (or between their deeply-held values and their
day-to-day behavior).
 Roll with resistance, guides therapists to accept client
reluctance to change as natural rather than pathological.
 Support self-efficacy, guides therapists to explicitly
embrace client autonomy (even when clients choose to not
change) and help clients move toward change successfully
and with confidence.
Motivational interviewing
Goals
Intervention
Component
Establish rapport.
Suggested strategies/
Questions
Use open-ended questions that
demonstrate concern for client
as a person.
‘How are you feeling today?
Are you comfortable?’
‘If I could see the situation
through your eyes, what would
I see?’
Get client agreement to talk
about topic.
Raise subject.
Request permission to discuss
topic.
‘Would you mind spending a
few minutes talking about
(topic) and how you see it
affecting your health?’
Understand readiness to
change behaviour and to
accept treatment/evaluation
referral.
Assess readiness.
Use of assessment tool to
assess readiness, and discuss
results with client.
‘How do you feel about
(topic)?’
‘How ready are you to change
your use of (topic)?’
Understanding client’s
concerns and circumstances.
Motivational interviewing II
Raise client awareness of
consequences of behaviour,
and share provider’s concerns.
Assure client that ongoing
support is available
Offer further support, targeted
to client’s level of readiness to
change.
For clients who are ’not ready’
to change:
‘Is there anything else you
want to know about (topic)?’
‘What would it take to get you
to consider thinking about a
change?’
For clients who are ‘unsure’
about change:
‘What are the good things you
like about (topic)? What does
it do for you?’
‘What are the things you don’t
like about (topic)? What
concerns do you have about
it?'
For clients who are ‘ready’ to
change:
‘Here are some options for
change. What do you think
would work best for you?’
Provide support and referral.
Questions