Transcript COMMUNICATION AND SUBSTANCE MISUSE - addiction

COMMUNICATION AND SUBSTANCE
MISUSE: THE BRIDGE BETWEEN
ASSESSMENT AND TREATMENT
March 2016






Identification of possible barriers to disclosure about
substance misuse
Recognition of effective ways of facilitating dialogue about
substance misuse
Appreciation of responding to patient cues
Use all available opportunities to ask about substance misuse
Communicate effectively when administering screening and
assessment tools
Understanding the principles of motivational interviewing
techniques








Presenting problems may be directly or indirectly (falls, fits,
confusion) related to substance use
Substance use can be difficult to uncover
The history taking needs to take these issues into account
Patients have varying needs so professionals need a range of skills
and techniques to respond to these different situations
Patients may be:
Embarrassed, frightened, defiant, cautious, secretive, aggressive,
angry, suspicious, in denial
May not wish to discuss these issues in the presence of family
Consider substance use a lifestyle choice and no business of a
professional






Questions need to be asked appropriately
Sensitivity, awareness and practice can improve communication
techniques
Patients may need reassurance about confidentiality and privacy
Keep an open mind and resist assumptions about race, religion
and sexuality
Students and patients need to realise that in some situations it is
not possible to guarantee confidentiality eg child protection or
safeguarding vulnerable adults
Screening tools need to be introduced in a sensitive and
sympathetic manner







Patients may feel
Apprehensive about divulging information about substance
misuse, and the impact this has on their life style
Fear being judged
Fear being stereotyped
That you do not have patience or time, or are distracted
Patients may tell staff what they think they want to hear
Open ended questions are more likely to yield more
information





All psychiatric assessments should routinely include systematic
substance use enquiry which should be empathic, non judgemental
and non confronational
Psychiatric disorders may lead to substance misuse, and substance
misuse may lead to psychiatric symptoms
Acute intoxication, withdrawal and chronic regular use of
substances may present with psychological symptoms
Mental state and physical examinations, investigations (urinary
drug screen, breathalyser) and collateral information should be
gathered and interpreted in the context of substance use
Consider possible life threatening conditions eg delirium tremens,
overdose, severe withdrawal, Wernicke Encephalopathy which
need emergency responses







Effective communication is a basic skill in the assessment and
care of a patient with substance problems. It comprises the
following:
Introductions and building rapport
Elicit change talk
Non-verbal communication
Active listening
Establishing a positive relationship
Giving patients information about substance misuse









Introduce yourself and thank the patient for agreeing to see you
Face the person with an open attentive posture
Maintain good eye contact
Listen carefully to what the patient has to say as this builds rapport
and understanding, and creates an atmosphere where they can feel
free to express their views
Ask difficult questions sensitively
Be empathic, respectful and non-judgemental
Elicit and respond to mental and physical health concerns
Identify, acknowledge and respond to difficult emotions
Reflection and summarising






Recognition of a substance problem, concerns about this,
intention, optimism and commitment to change
Use open directive questions
Questions such as:
Can you tell me about your current drinking?
What problems are causing concern? How m ight these be
affected by you substance use?
Tell me more about that?






Reflect back what the speaker is saying in other words to
clarify understanding
Summarise and bring new interpretations to the speaker’s
words which allows them to add information
Develop an empathic warm genuine relationship
Deal with emotional content of the sessions
Be non judgemental and non confrontational
Involve patients with decisions and care options






What is an appropriate treatment goal?
What motivation for psychological change?
What is the need for regular medical
assistance?
How appropriate are techniques for
assessment, advice, assistance and
arrangements? e.g. IT, telephone, larger
print
Ask Assess Advise Assist Prescribe
Arrange!
Consider post-treatment needs
 ASK
– routinely question and record
information
 ASSESS – comprehensive history
 ADVISE – brief intervention
 ASSIST – cognitive behavioural
 ARRANGE - admission
Ask all patients – record the
findings
 Style is a powerful determinant
 Awareness and sensitivity of
ambivalence
 Non-judgemental
 Non-confrontational style









Take a thorough, ongoing assessment which includes a
comprehensive history
Establish if there is dependence or not: assessment of
the severity of substance use, misuse and dependence
impact on treatment choice
There are many tools for screening, assessment and
monitoring outcome
Educate patient about withdrawal
Assess motivation – stage of change
Assess treatment goals: cessation or (harm) reduction
Consider treatment choices: pharmacological and
psychological
Consider the need for specialised services and admission










Brief interventions are:
5-10 minutes in duration
Use motivational interviewing techniques
Allow ventilation of anxieties and other problems
Personalised feedback about results of screening/blood tests
Provide information and education: personal benefits / risks
Provide information about safe levels eg drinking
Advise on ways to stop smoking, reduce drinking, reduce
medications or illicit drug use
Use a harm reduction approach
Provide of self-help materials







Offer support and encouragement
Instil positive expectations of success
Previous attempts to quit / cut down, low
confidence
Set ‘quit date’ – goal abstinence /
reduction
Get rid of substances
Offering a ‘menu’ of alternative coping
strategies
Identify cues: distract, escape, avoid, delay






Feedback which is personalised
Responsibility for change
Advice on how to change
Menu of options for change
Empathy: caring, understanding, warmth
Self efficacy: instil hope that change is within reach






Criteria for admission:
Severe physical illness
Comorbid severe mental illness eg
depression
Abuse multiple substances including OTC
and poorly compliant with prescribed
medications
Frequent relapses
Unstable social circumstances eg living
alone






Need to diagnose dependence
Management of withdrawal and detoxification
Vitamin replacement
Preventing relapse: promoting and maintaining abstinence
Reduction of harm associated
Implementation of psychological therapies



Need to diagnose dependence: Management of withdrawal
symptoms e.g. benzodiazepines, carbemazepine methadone,
clonidine, lofexidine buprenorphine
nicotine replacement, bupropion
Maintenance of abstinence e.g. methadone, buprenorphine
nicotine replacement, bupropion
Psychological therapies choice


Prevention of complications e.g. vitamin supplementation: Wernicke
Korsakoff’s syndrome Thiamine
Relapse prevention e.g. Acamprosate, naltrexone, disulfiram
1. Block pleasant effects: naltrexone
2. Reduce craving: acamprosate
3. Unpleasant reaction with alcohol: disulfiram



Treatment of psychiatric conditions e.g. depression
Treatment of physical conditions e.g. diabetes
Implementation of appropriate psychological therapies







Where and when to detoxify, if required
What are the medical risks?
What setting is appropriate?
Does the substance user want detoxification?
Does the patient realise that detoxification is the beginning of
treatment
How to integrate into the bigger treatment picture?
Communication with other health professionals and agencies
Bien TH, Miller WR, Tonigan JS (1993) Brief interventions for alcohol problems: a review. Addiction 88:315-35
Dunlop, A., Perry, N. and Robinson ,M. (2015) ‘ Therapeutic Relationship’, in Haber, P. Day, C. and Farrell, M. (ed)
Addiction Medicine Principles and Practice, Australia, IP Communications, pp104-113
Lloyd M & Bor R. (2009) Communication Skills for medicine, Edinburgh : Churchill Livingstone
Miller WR, Rollnick S. (2002) Motivational Interviewing: Preparing People to Change. New York, London, Guilford
Press.
NICE (2007) Drug misuse psychosocial interventions. Clinical Guideline 51. http://guidance.nice.org.uk/CG51
Rollnick S (2010) Motivational interviewing, BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c1900
http://www.bmj.com/content/340/bmj.c1900
Thistlewaite JE, Morris P. (2006) Patient-doctor Consultations in Primary Care: Theory and Practice. London: Royal
College of General Practitioners
Washer P (ed) (2009) Clinical Communication Skills. Oxford: Oxford University Press