Assessment as an intervention

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          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

        What are the key issues?
         How might you respond?
          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?

• 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

      Good GP Interviewers
• 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.
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
• 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 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 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.
  Conducive Conditions
AOD assessment is potentially an anxiety-
provoking 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.
        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 Domains

• Presenting problem and motivation for
• Drug use history and dependence severity
• Medical/psychiatric history
• Psychosocial history
• Examination
• Opportunities for harm reduction
• Formulate a negotiated treatment plan.

 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 /
• supported socially / emotionally?
• experiencing difficult social or interpersonal problems?
• aware of relevant and available treatment options?
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.

                   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 /
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

 • 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*.
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
    – psychiatric history, current and previous treatment
    – symptoms of depression (e.g., insomnia, suicidal
      ideation and attempts, depressed mood,
    – symptoms of anxiety (e.g., panic, social phobia).
• Mental state examination
    – mood, cognition, affect
• Physical examination, including:
    – nutritional status, weight
    – injection sites / trackmarks (number, location, skin
    – jaundice or stigmata of liver disease (e.g.,
      hepatomegaly etc.)
    – biochemistry, urine drug screen (if appropriate)
    – presence of intoxication or withdrawal.

      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.
          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?”
          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.

                                                Regular/ Excessive
   accidents/injury        I          R                health
 high-risk behaviour
                          impaired control
                       drug-centred behaviour
                          severe problems
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.
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).

   Extended Assessment (1)
How Did High-risk AOD Use Develop?
    – onset of regular use
    – factors associated with controlled,
      moderate use
    – factors associated with binges and
    – 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 •   Living / socialising circumstances
                                  •   Social / friendship networks
•   Mental health problems
    (family and patient)          •   Work culture

•   Social / economic deprivation•    High levels of stress

•   Ready accessibility           •   Relationship difficulties

•   Positive expectations of drug •   Lack of supports.

•   Possible comorbidity.
    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 /
     – 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.
            Treatment Plan
• whether the patient exhibits tolerance, or signs of
• 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?
Treatment Matching for AOD in
      General Practice
 Patients wants    Severity of               Treatment
 No intervention   Low risk      Provide information on risk
                   Medium risk   and recommended change
                   High risk     (i.e. Brief Intervention, Harm
                                 Reduction, e.g. safe injecting)
 To change         Low risk      BI, MI
 drug use          Medium risk   BI, MI
                   High risk     BI, MI,
                                 monitor for withdrawal risk,
                                 refer for specialist counselling

 Withdrawal        Low risk      Outpatient, home withdrawal
 management/       Medium risk   Outpatient, home, or
 detoxification                  non-medical withdrawal unit
                   High risk     Medical inpatient withdrawal unit
       GP Treatment Options
Harm           Discourage sharing
reduction      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,
               Advice re. ADIS, emergency services
               Provide and work through information booklets
               Encourage consideration of maintenance
Withdrawal     Clonidine
               Buprenorphine

Relapse     Supportive care
Prevention  Regular follow-up
               Encourage other forms of support or counselling