Transcript Assessment as an intervention

Assessment
Assessment
Case Vignette
Mary, 45, was recently charged with drink-driving while
taking her 4 children home from school. Recently
separated, she says her ‘nerves are shot’. She
attributes her anxiety to contact with her husband, and
admits to not dealing with issues terribly well at the
moment. She is mystified about the drink-driving
charge.
What are the key issues?
How might you respond?
Assessment
Case Vignette
Sarah, 17, presents for a prescription for the
contraceptive pill. She says she is looking forward to
the end of school, and the fun of ‘schoolies’ week.
She is an avid dancer, and her 24 year-old boyfriend
is a keen ‘hydroponic’ gardener. You are also the GP
for her parents.
What may be the key issues for you?
What are Sarah’s priorities?
How might you respond?
Assessment
Assessment
• Is a two way process – you are both
appraising each other
• Does not begin and end with the first contact –
it continues until the patient leaves the practice
• Constitutes the beginning of the intervention
• Is a reflection of the thinking and beliefs of the
assessor.
Assessment
Good GP Interviewers
Display:
• interest and attention
• empathy
• warmth
• active listening skills
• thoughtfulness (wisdom and knowledge)
• reflectiveness
• an inability to be shocked
• a non-judgmental stance that does not blur into collusion
• a style of questioning that enquires in an open,
non-confrontational way about simple, recent issues.
Assessment
An Unsuccessful Assessment
“At worst the client will leave
confused, disempowered, helpless
and in need of a cigarette, a drink,
a fix and a lie down in a
darkened room.”
McBride (2002, p. 76)
Assessment
A Competent GP Assessment
Will Have...
• Brought some clarity (to both patient and doctor) about
what may seem like a “chaotic array of happenings”
• Built rapport and instilled a sense of direction
• Indicated areas in need of urgent attention
• Identified areas that will benefit from harm minimisation
strategies
• Provided a basis for treatment recommendations.
Edwards (1987)
Assessment
A Successful GP Assessment
Leaves patients with:
• a clearer understanding of their difficulties and
how these relate to their drug use
• confidence in the doctor
• a clear understanding of what can be done
• achievable goals
• optimism about their ability to change.
Assessment
Assessment as Treatment (1)
• Helps the doctor and patient, working together,
to link high-risk AOD use to:
– past life experiences and expectations
– lifestyle, social and occupational factors
– physical and psychological conditions
– motivation for reducing / ceasing AOD use
• Essential for formulating an individually
tailored and negotiated treatment plan.
Assessment
Assessment as Treatment (2)
“Whether intentionally or not,
this meeting
(the assessment) has
a large therapeutic component and the
relationship established with the patient
may well determine whether he or she
returns again or accepts
recommendations for change”
Assessment often continues throughout treatment as
new issues are identified and progress is monitored.
Assessment
Conducive Conditions
AOD assessment is potentially an anxietyprovoking experience (for both doctor and
patient), so it is crucial to:
– be non-judgmental; recognise that drug
use serves a useful purpose for the patient
– have sound counselling skills (e.g., gently
probe with plenty of open-ended questions;
actively listen; summarise)
– reassure and support the patient.
Assessment
Key Questions
How will undertaking an AOD assessment
make a difference to your practice?
What are the barriers to assessing
a patient’s use of psychoactive drugs?
Assessment
Assessment Domains
• Presenting problem and motivation for
treatment
• Drug use history and dependence severity
• Medical/psychiatric history
• Psychosocial history
• Examination
• Opportunities for harm reduction
• Formulate a negotiated treatment plan.
Assessment
Critical Issues for Clarification
What is the patient requesting or seeking from you?
Is the patient:
• dependent?
(how severe? dependent on more than one drug?)
• motivated or ‘ready’ to seek treatment or a change in
circumstances? Do they have the skills or ability to do so?
• experiencing significant comorbidity (medical /
psychiatric?)
• supported socially / emotionally?
• experiencing difficult social or interpersonal problems?
• aware of relevant and available treatment options?
Assessment
A Patient’s Understanding of AOD Use
and Related Problems
• Under which conditions has the patient previously
controlled / ceased use – when, why and how?
• What conditions are most strongly associated with
impaired control and relapse?
• What is rewarding about the drug use? What factors
maintain the pattern of use? Try and establish:
– triggers / antecedents of use
– consequences of use e.g., mood and perceptual
changes, intoxicated behaviour.
Assessment
AOD History
The GP needs to ask about:
•
type of drug/s used
•
pattern of use (duration, quantity, frequency of use, last 1–3 days,
and last month, and whether continuous or binge)
•
when last used
•
other drugs used (current, concurrent, and previous, reasons and
patterns of use of other drugs)
•
route/s of administration
•
history of use (age commenced, periods of abstinence)
•
dependence severity
•
circumstances and consequences of use
•
previous treatment (past withdrawal history, attempts to cut down /
stop).
Assessment
AOD History: The Last 24 Hours
Obtain information about the quantity and
frequency of drugs used in the last 24 hours to:
• help determine the state of intoxication upon
presentation
• gauge tolerance and degree of dependence
• help assess withdrawal needs (e.g., if and when
onset of withdrawal is likely?)
• determine dosage – may require calculation, with
the patient’s help, from $ value to weight*.
Assessment
Medical and Psychiatric History
• Pregnancy
• HIV, hepatitis B or C infection
• Major or unstable medical conditions
• Unstable psychiatric conditions (e.g., active psychosis,
severe depression with suicidality, mentally
disordered)
– psychiatric history, current and previous treatment
– symptoms of depression (e.g., insomnia, suicidal
ideation and attempts, depressed mood,
anhedonia)
– symptoms of anxiety (e.g., panic, social phobia).
Assessment
Examination
• Mental state examination
– mood, cognition, affect
• Physical examination, including:
– nutritional status, weight
– injection sites / trackmarks (number, location, skin
health)
– jaundice or stigmata of liver disease (e.g.,
hepatomegaly etc.)
– biochemistry, urine drug screen (if appropriate)
– presence of intoxication or withdrawal.
Assessment
Psychosocial History
• Relationships, family, social supports
and activities
• Education and employment
• Legal issues (pending)
• Living circumstances
(stability, affordability)
• Finances (legal sources of income)
• Involvement with other agencies.
Assessment
How Do I Ask?
“When did you start using?”
“Have you stopped before and if so, for how long?”
“What led you back to using?”
“Have you had any treatment and what was
the outcome?”
“What do you like about using drugs?”
“In what ways does drug use help you to cope?”
“What concerns you about your drug use?”
Assessment
Types of Problems
Different patterns of drug use result in different types of problems.
Drug use may affect all areas of a patient’s life and problems are not
restricted to dependent drug use.
Intoxication
accidents/injury
poisoning/hangovers
absenteeism
high-risk behaviour
I
R
Regular/ Excessive
Use
health
finances
relationships
D
Dependence
impaired control
drug-centred behaviour
severe problems
withdrawal
Assessment
Is the Patient Dependent? (1)
Features of dependence include:
• increasing tolerance to the effects of the drug
• a need to increase the dose to achieve the
desired effect
• past experience of withdrawal
• further use to avoid the onset of withdrawal
• after a period of abstinence
(voluntary or enforced), rapid reinstatement of
the dependent pattern of use.
Assessment
Is the Patient Dependent? (2)
Severe dependence manifests as:
– a lifestyle revolving around drug use
– significant drug-seeking behaviour unless
the drug is readily available
– consistency in the drug use pattern
– a sense of impaired control (the user has
tried to restrict use and failed to do so).
Assessment
Extended Assessment (1)
How Did High-risk AOD Use Develop?
Identify:
– onset of regular use
– factors associated with controlled,
moderate use
– factors associated with binges and
escalation
– if signs of dependence, establish its onset
– are there legal, physical, relationship
consequences?
Assessment
Extended Assessment (2)
History, Lifestyle and High-risk Use
HISTORY
•
LIFESTYLE
Physical / sexual / emotional •
abuse
•
Mental health problems
•
(family and patient)
Living / socialising circumstances
•
Social / economic deprivation•
High levels of stress
•
Ready accessibility
•
Positive expectations of drug •
effects
•
Possible comorbidity.
•
•
Social / friendship networks
Work culture
Relationship difficulties
Lack of supports.
Assessment
Extended Assessment (3)
Is Work Contributing to High-risk Use?
Some jobs are inherently risky because:
– psychoactive drug use is part of work culture
– work provides subsidised alcohol at outlets /
functions
– drugs are available on-site
– working hours are flexible
– little supervision occurs
– the work is in isolated areas / person away from
normal obligations and commitments
– the work is stressful.
Assessment
Treatment Plan
Identify:
• whether the patient exhibits tolerance, or signs of
dependence
• patient’s interest in managing dependence
(wants and needs)
• does the patient use, or is the patient dependent on,
other drugs
• Is the patient interested in change
• does the patient have social supports to enable
successful intervention
• is the patient experiencing coexisting medical or
mental health problems?
Assessment
Treatment Matching for AOD in
General Practice
Patients wants
No intervention
Severity of
problem
Low risk
Medium risk
High risk
Treatment
Provide information on risk
and recommended change
(i.e. Brief Intervention, Harm
Reduction, e.g. safe injecting)
To change
drug use
Low risk
Medium risk
High risk
BI, MI
BI, MI
BI, MI,
monitor for withdrawal risk,
refer for specialist counselling
Withdrawal
management/
detoxification
Low risk
Medium risk
Outpatient, home withdrawal
Outpatient, home, or
non-medical withdrawal unit
Medical inpatient withdrawal unit
High risk
Assessment
GP Treatment Options
Harm
reduction
Withdrawal
 Discourage sharing
 Encourage awareness of BBV transmission risks
 Prevention issues – contraception, STDs
 Teach about overdose risks and responses of
emergency services
 Encourage qualifying in, or teach, resuscitation,
CPR
 Advice re. ADIS, emergency services
 Provide and work through information booklets
 Encourage consideration of maintenance
therapies
 Clonidine
 Buprenorphine
 Supportive care
Relapse
Prevention  Regular follow-up
 Encourage other forms of support or counselling
Assessment