Assessment

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. Case Vignette 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 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 “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 as Treatment (2) Assessment often continues throughout treatment as new issues are identified and progress is monitored.

Assessment 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.

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 Regular/ Excessive Use health finances relationships Dependence impaired control drug-centred behaviour severe problems withdrawal I R D

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 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). Is the Patient Dependent? (2)

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 Physical / sexual / emotional abuse Mental health problems (family and patient) Social / economic deprivation Ready accessibility Positive expectations of drug effects Possible comorbidity. LIFESTYLE Living / socialising circumstances Social / friendship networks Work culture High levels of stress 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

Assessment GP Treatment Options Assessment