1. Clinical Framework

2. Clinical Framework Troy, an 18 year old, has recently presented twice on Tuesday mornings requesting a sick certificate for the day before for seemingly ‘thin’ reasons, following a ‘heavy’ weekend. You probably need to find out more….. Could drugs be involved in any way? How do you start?

3. Clinical Framework Key Considerations Individual patient issues Patterns of drug use ? Associated problems ? Dependence ? Associated behaviours

4. Clinical Framework Identifying and Responding to AOD Problems Non-problematic, low risk use No major lifestyle disruptions, and not dependent Most commonly seen group in GP setting. May present with unrelated complaint e.g. hangovers, school/work problems, drink driving charges, MVA, poor sleep or depression Detected by GP asking lifestyle question. Great potential for GP intervention with high likelihood of ‘success’. Dependence Major lifestyle disruption, significant dependence Easier to detect but less easy to change. May take many attempts to achieve goal. May be associated with challenging behaviour. Risky or high risk use The severity of the problem determines treatment goals and treatment options.

5. Clinical Framework 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 child neglect Dependence impaired control drug-centred behaviour anxiety / isolation / social problems withdrawal I R D

6. Clinical Framework 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 child neglect Dependence impaired control drug-centred behaviour anxiety/isolation/social problems withdrawal I R D

7. Clinical Framework Types of Problems (RU) Vein damage Vein damage Infections Organ Disease Infections Organ Disease Relationships Relationships Financial Financial Vein damage Vein damage Infections Organ Disease Infections Organ Disease Relationships Relationships Financial Financial IntoxicationIntoxication · Regular Use

8. Clinical Framework Types of Problems (D) IntoxicationIntoxication Withdrawal Withdrawal Craving Craving Obsessive Obsessive Cognitive Conflict Cognitive Conflict Loss of Control Loss of Control Withdrawal Withdrawal Craving Craving Obsessive Obsessive Cognitive Conflict Cognitive Conflict Loss of Control Loss of Control Regular Use · Dependence

9. Clinical Framework Types of Problems: Clinical Samples Intox. Regular Use Dependence

10. Clinical Framework How Do You Start? Consider using open-ended questions such as: ‘Are you healthy and well? Do you eat well? Do you exercise? Even commonly used drugs can affect our health. Do you smoke? What about cannabis? Do you use pills? Do you inject? Take anything else?’ You may need to clarify quantities, frequency, context of use etc.

11. Clinical Framework Troy’s Response - 1 Troy says he only drinks at weekends when he often goes to parties. He tells you he drinks 6 cans of Jack Daniels most Saturdays and uses one or two ecstasy tablets about once a month. This last weekend he drank a bit more - about double his usual amount and consequently was ‘hung-over’ on Monday. How could you respond? Is it worth trying to find out more? What might Troy think about your response? Is he likely to change?

12. Clinical Framework Troy’s Response - 2 Troy says he usually drinks about half a bottle of whisky on a Saturday night (shares a bottle with a friend) but he drank a whole bottle last weekend. He got into a fight about his girlfriend and then stormed off and got picked up by the police with a BAC of 0.17 - he was still angry so was put in a cell overnight. This is his second offence. Does this change your response? What might Troy think about your response? Is he likely to change?

13. Clinical Framework Troy’s Response - 3 Troy says he doesn’t usually drink much - maybe a 4 pack of Jack Daniels once a week. He has been smoking cannabis on and off since he was 13 years old; for the last 18 months he’s smoked about 10 cones a day. Yesterday he had no money so didn’t use any cannabis. Ask: ‘Can you tell me how you felt yesterday after going without cannabis?’ How could you explore if he wants to quit? What might Troy think about your response? What could you do?

14. Clinical Framework Troy’s Response - 4 Instead of asking for a sick certificate Troy wants a script for benzos. When you ask him to tell you more he says he uses heroin most days and needs the benzos because he hasn’t got any money to ‘score’ and wants to try and stop. You refuse and he gets aggressive and demanding - saying you are ‘forcing him to go out and use’. How could you respond? What can you do to minimise harm to Troy - what might he think about your response? Is he likely to change?

15. Clinical Framework Assisting Assessment and Response In thinking about and responding to patients with drug use issues it can help to have a framework that assists in the formulation of a comprehensive assessment and relevant response Significant factors likely to impact on successful management include: a patient’s readiness to change psychosocial / medical factors that facilitate or restrict change physical & psychological harm from drug use Not everything needs to be done at once.

16. Clinical Framework Domains to Explore - A Clinician’s View and Rationale Pattern of drug use - to identify both patterns and problems associated with particular patterns of use, prevent complications and intervene early (? prevent progression) Degree of dependence (if at all) - to identify need for and appropriate withdrawal management, medication etc and facilitate reliable mental state assessment Dysfunctional cognition and behaviour - to identify likely complicating issues, limit prescribing harms, screen for underlying contributing conditions e.g. PTSD.

17. Clinical Framework For Each Domain Consider: Key features (of regular use, intoxication or dependence) Key clinical indicators Useful features in history and presentation Different identification and response potential Key issues to ensure appropriate assessment in GP setting Please refer to Handout 1

18. Clinical Framework A Clinical Framework DependencePatterns & Problems Associated Behaviours Patient Choices 3 Domains to Explore Continue +/- unchanged Modification Stop Substitution Treatment Approach Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral I R D

19. Clinical Framework Using the Framework in Practice Troy 1 Patient Choices Continue +/- unchanged ? Modification ? Stop ? Substitution Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral drinks 6 cans of Jack Daniels most Saturdays at parties uses 1 or 2 ecstasy tabs. about once a month last weekend, drank about double his usual - ‘hung-over’ on Monday. 2nd time presented for sick certificate Low Risk Risky High Risk Dependence Associated Behaviours Patterns & Problems I R D

20. Clinical Framework Patient Choices Continue +/- unchanged ? Modification ? Stop ? Substitution Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Using the Framework in Practice Troy 2 drinks half a bottle of whisky - Sat. nights with his mate whole bottle last w/end fight with girlfriend, stormed off picked up by police with BAC 0.17 spent night in cell - 2nd offence I R D Low Risk Risky High Risk Dependence Associated Behaviours Patterns & Problems

21. Clinical Framework Patient Choices Continue +/- unchanged ? Modification ? Stop ? Substitution Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Using the Framework in Practice Troy 3 drinks 4 pack Jack Daniels/once a week smoking cannabis on/off since age 13 last 18 months, smoked about 10 cones daily yesterday, no money so went without Low Risk Risky High Risk Psychological /physical withdrawal features ? 2 drugs Dependence Associated Behaviours Patterns & Problems I R D

22. Clinical Framework Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Patient Choices Continue +/- unchanged ? Modification ? Stop ? Substitution ? Addictive Behaviours Low Risk Risky High Risk Psychological /physical withdrawal features ? Dependence Associated Behaviours Patterns & Problems Using the Framework in Practice Troy 4 wants benzo script almost daily heroin no money, ? wants to stop heroin script refusal ---> aggression I R D

23. Clinical Framework Opportunities for Intervention Presenting Complaint related to AOD ? related to AOD but patient unaware of link clearly AOD related drug seeking Action identify use level and patterns, encourage behaviour change if appropriate and reduce harms where relevant link symptoms / problems i.e. personalise drug effects & offer help engage in therapeutic relationship, offer controlled safer drug regime, harm reduction until cessation is possible emphasise link and offer help

24. Clinical Framework Treatment Responses Please refer to Handout 2

25. Clinical Framework Degree of DependencePatterns & Problems Associated Behaviours Patient Choices Continue +/- unchanged Modification Stop Substitution Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Addictive Behaviours Low Risk Risky High Risk Psych ological /physical withdrawal features Patient …. I R D