Transcript Drug and Alcohol Use

4: Drug and
Alcohol use
Prepared by J. Mabbutt & C. Maynard
NaMO
September 2008
4: Drug and Alcohol use
assessment: Objectives
1.
By the end of the session nurses & midwives will have an increase in
their knowledge & skills to enable them to take a basic drug & alcohol
use history & also to be aware of the broad issues regarding a thorough
assessment
2.
During the session nurses & midwives will participate in teaching activities
to improve their ability to complete a basic drug and alcohol
use history & increase their knowledge regarding a thorough assessment
4: Drug and Alcohol use assessment (1)

Nurses & midwives are well placed to assess, manage and intervene
with someone’s drug & alcohol use

It is essential that nurses and midwives are well-equipped to identify
presentations that require admission, treatment, referral or further
investigation

Refer to NSW Health Policy, 2007 – “Nursing and Midwifery Management
of Drug and Alcohol Issues in the Delivery of Health Care” for further
information
4: Drug and Alcohol use assessment (2)
A drug & alcohol use assessment is important in order to:

Establish a correct diagnosis

Predict the effects of intoxication, assess its life-threatening potential,
& plan appropriate intervention

Assess the possibility of drug interaction between the drug taken by
the patient and drug(s) administered by the nurse, or between those
already taken
4: Drug and Alcohol use assessment (3)

Predict the possibility of withdrawal

Assess risk behaviours, including self harm

Ensure duty of care

Gain an understanding of the patient as a whole person,
not merely in terms of their symptoms

Select appropriate therapeutic interventions
4: Drug and Alcohol use assessment (4)

Some diagnoses may be confused with alcohol or drug intoxication
or withdrawal

This can lead to significant medical problems being missed if the
nurse or midwife does not look for causes beyond alcohol or drugs

Such problems include infection, hypoxia, hypoglycaemia and other
metabolic imbalances, head injury, CVA, liver disease, drug overdose and
psychosis
4: General principles of Drug
& Alcohol use assessment

A systematic drug & alcohol use assessment of all patients, quantified
& documented, including a thorough examination of:
– indicators of risk
– past medical history
– psychosocial issues
– physical signs & symptoms
– mental health status & pathology results

No single sign, symptom or pathology test is conclusive evidence
of an alcohol or drug-related issue
4: Key elements of assessment (1)
The following key elements must be clarified with each patient
as part of an assessment:

Type of drug (See Appendix 6 for street names)

Route of administration

Frequency of use

Dose & duration of use

Time & amount of the last dose, e.g. grams of alcohol or number
of standard drinks, mls and mgs of methadone, grams of cannabis, etc
4: Key elements of assessment (2)

NOTE: It is important to ask the person if they are using more than one
drug at a time, as polydrug use can significantly increase the risk involved
4: Quantifying substance use (1)

A person’s drug & alcohol use must be quantified, & include both prescribed
& non-prescribed drugs

Determine whether the level of use may cause harm, and whether withdrawal
or progression to overdose is imminent

For some substances such as alcohol, there is an agreed low risk level of
consumption

For tobacco there is no safe level of consumption
4: Quantifying substance use (2)

Illicit drugs are difficult to quantify because the same drug can differ vastly
from dose to dose in terms of purity & actual ingredients.

Nevertheless, for illicit drugs, document e.g. the number of injections, bongs,
or the dollar cost or amount used (e.g. grams)

Many medications should only be taken if they are on prescription & in the
way prescribed
4: Confidentiality

Explain the patient’s right to privacy & any limits to confidentiality, e.g. if there
are child protection issues

Patients need to be informed that the purpose of taking a drug & alcohol history
is to obtain information that is relevant to their health / not a forensic investigation.

Information in most cases, can only be provided to third parties with written
permission

Exceptions, for example, if the person is homicidal or suicidal; if there are current
child protection issues or if a subpoena has been issued for the patient’s notes
4: Signs of drug & alcohol use
administration: Some examples

Smell of alcohol

Signs of alcohol use (see alcohol withdrawal presentation)

Puncture marks

Cellulitis/phlebitis

Skin abscesses

erosion or irritation around nostrils/septum

Irritation or rash around nose and mouth
4: Signs of withdrawal
Some examples

Sweating

Tremor

Agitation

Disturbance of coordination, gait

Gooseflesh

Dilated pupils

Leg, stomach cramps
4: Consequences of use

Excessive weight loss, signs of numerous old injuries, e.g. bruising

General physical health problems such as septicaemia, HIV, hepatitis B/C, jaundice

Mental health illness, treatment, involuntary admissions

Psychological distress/needing to do sex work/victim of rape/violence

Crime, jail, stealing from family & friends, selling possessions

Loss of relationships, employment, housing, savings etc
4: Mental Status Examination (1)

Appearance & behaviour

Speech

Mood

Affect

Thought form; Thought content

Perception

Insight & Judgment
4: Mental Status Examination (2)

All health staff need to complete a preliminary screening for suicide risk as
part of any assessment

Refer to NSW Health Department Policy PD2005_121 ‘Management of
patients with possible suicidal behaviour.’ (there is also a CD-ROM
resource for Mental Health and Non Mental Health Workers)

Refer also to NSW Mental Health Outcomes & Assessment Training Project
(MH-OAT) developed to improve assessment skills for mental health staff
HIV, Hepatitis B & C Screening, Child
Protection & Domestic Violence Issues

Besides the information that has been presented so far that needs to be
collected on admission, there is some other important information to assess

The next slides cover three of a number important issues that should be part
of an assessment

Child Protection & Domestic Violence screening are mandatory

HIV, Hepatitis B & C screening should also be part of any assessment,
especially that hepatitis B is vaccine preventable and the high rate of
Hepatitis C in injecting drug users
4.8 HIV, Hepatitis B & C Screening

Hepatitis C is a major public health concern in Australia

Offer all patients screening for HIV, hepatitis B & C & advise on the
availability of hepatitis B vaccination

Pre-test and post-test counselling must be provided as outlined in: NSW
Health Policy Directive PD2005_048: Counselling associated with HIV
antibody testing – guidelines.

For further information, see ‘Nurses & Hepatitis C’ – Australasian Society
for HIV Medicine (ASHM) http://www.ashm.org.au/uploads/File/nursessupp.pdf
4.9 Child Protection Issues (1)

Health care workers have a duty under the NSW Children and Young
Persons (Care and Protection) Act 1998 to notify the Department of
Community Services whenever they suspect that a child or young person
may be at risk of harm through abuse or neglect

It is important to note that drug & alcohol issue by a parent does not
automatically equate to a child or young person being at risk

For further information, refer to: NSW Health Policy Directive
PD2005_299. Protecting children and young people

NSW Health Frontline Procedures for the protection of children
and young people. 2000
4.9 Child Protection Issues (2)

Pregnant opioid-dependent women should always be referred to
Drug Use in Pregnancy Services

For further information, refer to the National clinical guidelines for
the management of drug use during pregnancy, birth and the
early development years of the newborn. (March 2006)
http://www.health.nsw.gov.au/pubs/2006/ncg_druguse.html

NSW Health Neonatal Abstinence Syndrome (NAS) Guidelines,
2005 focus on care of opioid dependant women and care of the
newborn from a child protection perspective
http://www.health.nsw.gov.au/policies/pd/2005/PD2005_494.html
4: Domestic violence issues

Amongst those with drug & alcohol issues are significant numbers of both
victims and perpetrators of domestic violence. Responding to this group
presents particular challenges for nurses

For further information about the management of domestic violence and
assessment of risk, refer to:

NSW Health Policy for Identifying and Responding to Domestic
Violence, 2003

NSW Health Policy Directive PD2006_084. Identifying and
responding to domestic violence
4: Hints on taking a drug & alcohol
history (1)
Here are some points to remember when taking a history:

Normalise the assessment by telling the patient that you ask
these questions to all patients

Try to make the environment as quiet and private as possible

Be mindful of the patient’s level of physical & emotional comfort

Note inconsistencies in what the patient tells you
4: Hints on taking a drug & alcohol
history (2)

If a question angers the patient, leave it until later when you can rephrase
the question

A history of the person’s drug and alcohol use can also be elicited from
their spouse, friends or family, with the patients consent

Examine hospital medical records and speak to other health workers to
gain supporting information for your history
4: Hints on taking a drug & alcohol
history (3)

When discussing drug & alcohol issues try to remain as non-threatening
and non-judgmental as possible
The following techniques may help, but be mindful that they may
not be suitable for every patient. Use discretion and professional
judgment as to which may be useful

Introduce drinking/drug use as a normal, everyday experience, e.g.
“What do you like to drink each day?

Ask about frequency of use e.g. “how often would you have a drink/use
heroin/cannabis?” or ask “what is a typical day of drug use?”
4: Hints on taking a drug & alcohol
history (4)

Use open-ended questions, e.g. “How has your drinking/drug use
changed over time?”

Try reflective listening, e.g. “Sounds like your drinking has been
causing you problems lately”

Do not be distracted away from important points

Do not allow personal attitudes to affect the assessment

Be affirmative, e.g. “It takes a lot of courage to open up and talk
about your drug use”
4: Hints on taking a drug & alcohol
history (5)

Be sensitive to the patient’s cultural background & language

Suggest high levels of drug and alcohol use, e.g. “How much would
you normally drink in a session? Twenty schooners?”

However, when talking with adolescents, be careful that they do not
perceive the overestimated amount as an expected figure, thereby
encouraging them to exaggerate it further
4: Hints on taking a drug & alcohol
history (6)

Summarise, e.g. “On the one hand you like drinking because it helps
you to relax but on the other hand you’re concerned about the effect
it will have on the kids.”

Do not assume that the patient perceives their drug & alcohol use
as a problem

If you don’t understand the jargon, ask the patient to explain

See a following slide for street names of drugs
4: Quantifying substance use
Don’t be afraid to ask

Even ‘experts’ in the drug & alcohol field, may not know a street drug name

So, don’t be afraid to ask about the name, what another name is used for the
drug, how it effects the person

By asking these questions you should be able to have a good idea what type
of drug it is, by not asking you are not completing an assessment!

Surprisingly, drug uses will volunteer a lot of information about drugs to
people who come across as interested, wanting to help & not judgmental –
so ask!
Approved name of drug
Street name
Price in NSW, 2004-5 *
Alcohol
Grog, piss, booze, sauce
Amphetamines
Speed, goey, whiz, uppers, oxblood,
point, crystal, crystal meth, ice, shabu
Benzodiazepines
benzos, rowies, moggies, downers,
sleepers, tummies, series, pills
Cannabis
marijuana, grass, pot, shit, ganja, mull,
hash, durry, green, dope, cone
Leaf- Ounce (28 g) $150
Head- Ounce (28 g) $200
Hydroponic- (28 g) $250
Hash/resin- Deal (1g ) $50
Cocaine
Snow, coke
1 gram $150–$300
Ecstasy
E, eccies, XTC, fantasy, GBH, liquid
ecstasy, good speed
1 tablet/capsule $30–$70
Heroin/ opioids
Hammer, H, shit, smack, horse, harry,
white, skag, junk
1 taste/cap (0.1–0.3 g) $50
Full gram $200–$500
1 weight gram $90–$500
4: Appendix 6: Street names of drugs
* Adapted from the Illicit Drug Data Report. 2004–05 Australian Crime Commission
* Adapted from the Illicit Drug Data Report. 2004–05 Australian Crime Commission
Approved name of drug
Street name
Price in NSW, 2004-5 *
Ketamine
Special K
Varied across States: ACT $65 S.A. - $200
Lysergic acid diethylamide
(LSD)
Acid, blotter, trips, wangers, tabs, dots
$10 to $25 per tab
Methylene
Dioxyamphetamine (MDA)
Adam
1 tablet/capsule $30–$70
Methylene
Dioxymethamphetamine
(MDMA)
Ecstasy, Utopia, E, XTC
1 tablet/capsule $30–$70
Phencyclidine (PCP)
Angel dust
PMA
Dr Death
Psilocybin
Magic mushrooms, gold tops
Solvents
glue, tol, toluene, bute, nitrus, amyls,
petrol, super, aerosol paint-chroming
4: Appendix 6: Street names of drugs
* Adapted from the Illicit Drug Data Report. 2004–05 Australian Crime Commission
4: Assessment – Activity 3:
Low risk – high risk Admission game
1.
Handout cards with scenarios to participants (distribute) all cards (or use
projector)
2.
Lay the risk plates (4) across the floor
3.
One participant reads out their card (or takes it in turn via the projector),
then places it (or indicates which of the risk plates it relates to) on a risk plates.
They are asked to explain why on that plate. They may fill in the gaps in the
scenario to justify their decision. The group may assist.
4.
A second participant continues this process until all scenarios are completed
the time allocated is over.
RPA Education Unit CSAHS – Powell, Keen & Brown 1994
4: Assessment – Activity 4:
Admission role play activity (1)
1.
One nurse, patient and observer
2.
The setting is on the ward 1 hour after admission
3.
The patient is given a role play card which is not shown to the nurse, but
the patient tells the nurse the reason for the admission. The nurse asks
the patient about their substance use history. If this is a local substance
use assessment tool is it recorded on that or just on a piece of paper in
a systematic way, one at a time.
4.
The observers only record information for constructive feedback.
RPA Education Unit CSAHS – Powell, Keen & Brown 1994
4: Assessment
Admission role play activity 4 (2)
5.
Patients are not to overact and should make it fairly easy for the nurse!
6.
At the end of the time period the nurse and patient swap chairs. The
nurse debriefs about what the experience was like, then is followed by
the patient and the observer.
7.
The nurse can now look at the role play card to see how accurate they
were in the assessment
8.
This is not a test, just practice, so relax!
Developed by Mabbutt 2003
4: Assessment
Admission role play activity 4 (3)

The following key elements must be clarified with each patient
as part of an assessment. Use these questions in the role play:

Type of drug (See Appendix 6 for street names)

Route of administration

Frequency of use

Dose & duration of use

Time & amount of the last dose, e.g. grams of alcohol or number
of standard drinks, mls & mgs of methadone, grams of cannabis, etc
4: Assessment
Quantifying an alcohol history
Show either of the videos below from the CIWAR-Ar CD- ROM
and discuss

E3 Early detection of people at risk (alcohol) (9.04 min)

E4 Quantifying an alcohol history & Brief intervention using the
AUDIT & Drinkless Resource (6.18 min)

See Opportunistic Intervention presentation No 5 for more
details on the use of the AUDIT and Intervention re alcohol use