1. Early Recognition & Screening Early Recognition & Screening

2. Early Recognition & Screening Early Recognition of Problematic AOD Use Many people who use illicit drugs are reluctant to reveal their use or related problems A professional empathetic approach (open, non-judgmental) will assist to build rapport, to elicit an accurate AOD history A range of indicators (medical, behavioural or psychosocial) may prompt further investigation.

3. Early Recognition & Screening Medical Indicators of Problematic AOD Use Drug-related complications –side effects (e.g., constipation, hallucinations) –overdose (e.g., respiratory depression) –withdrawal (e.g., irritability, depression) –foreign body injection (e.g., CVA, endocarditis) Sharing injecting equipment –BBV Route-specific –smoking (asthma, respiratory problems) –injecting (poor venous access, cellulitis) –intranasal (nasal septal damage, rhinnorhoea) General health –anaemia, poor nutrition or dental hygiene, weight loss, loss of libido

4. Early Recognition & Screening Behavioural Indicators of Problematic AOD Use Presenting after hours Multiple presentations for painful conditions Use of medical terminology Loss of scripts or medication / requests for specific drugs Changed physical appearance over time (change in grooming)  job/school performance, missed appointments Trauma, poor concentration Conflicts with others Intolerant or ‘allergic’ to suggested alternatives Specific withdrawal symptoms.

5. Early Recognition & Screening Multiple medical contacts Many contacts with Emergency Departments Depression Family history of problematic AOD use Partner who uses alcohol or other drugs Psychiatric treatment Young age or adolescent – withdrawal from school, friends, family Generally  social functioning. Psychosocial Indicators of Problematic AOD Use

6. Early Recognition & Screening GPs Are Well Placed to Detect AOD Issues Because...  85% of people visit a GP at least yearly  GPs and PHC professionals are usually first point of contact with the health care system  GPs are ideally placed to link prevention with comprehensive, continuing, and holistic care  GPs provide services spanning the health care continuum, from illness prevention to treatment and rehabilitation  Patients expect GPs to:  provide lifestyle advice  ask about their use of AOD.

7. Early Recognition & Screening Screening Commonly performed in health settings Generally well accepted Detects the likelihood of need for diagnosis, and informs need for further investigation Screening instruments specific to AOD use: –can suggest a diagnosis / indicate problematic use –allow for a simple (often self-report) approach to information gathering.

8. Early Recognition & Screening AOD Issues Are Often Missed Because… AOD issues are difficult to detect GPs unsure how to respond, or if they should Symptoms may mimic other conditions Inadequate role models or role support for GPs GPs are embarrassed to ask, concerned about patient evasion, or unsure about treatment effectiveness GPs perceive AOD is the domain of ‘specialists’.

9. Early Recognition & Screening Routine AOD Screening is Appropriate for... General hospital patients –esp. liver, neurological, cardiovascular disorders, MVA / trauma ED/casualty presentations People who are depressed / suicidal, or have mental health problems General Practice patients Special groups (e.g., homeless, prisoners) People with AOD-related legal offences (e.g., DUI).

10. Early Recognition & Screening Benefits of Screening Informs diagnosis Provides opportunity for education Alerts GP to risks for interactions with medications or other aspects of treatment Offers opportunities to engage For people not dependent, screening has proved beneficial in reducing high-risk activities.

11. Early Recognition & Screening Who Should Be Screened? All new patients Patients with chronic problems Patients with acute problems Patients seeking pre-conception and antenatal care. Note: Enhanced Primary Care Medicare Benefit Schedule items.

12. Early Recognition & Screening To Improve Detection Use: routine inquiry screening questionnaires –e.g., CAGE / AUDIT biological screening (pathology tests) –e.g., blood, liver function, hep B and C serology, urine knowledge of common indicators and clinical presentations consistent with problematic use. In General Practice, AOD issues are often missed amongst women, the elderly and among people who are not ready to address high-risk use.

13. Early Recognition & Screening Screening Instruments (1) 1To screen for, and identify, problematic AOD use –e.g., AUDIT 2To identify frequency and quantity of use –e.g., DrugCheck –useful for diagnostic purposes and establishing treatment goals 3To assess for severity of dependence –e.g., SDS –sensitive to dependence and for monitoring over time –not sensitive to low-level problematic use.

14. Early Recognition & Screening Screening Instruments (2) Biochemical measures: –e.g., urine, bloods –usually expensive and insensitive –useful if validation of recent use is required –like quantity / frequency measures, fail to provide information on psychosocial impact of drug use Screening tools cannot replace a clinical interview!

15. Early Recognition & Screening Screening Instruments (3) Should be selected for specific purposes: –few tools have cross-cultural applicability –should be used according to patient’s capacity for completion –consider the role of the tool in informing treatment Ideally, have been appropriately validated Usually provide cheap, instant results Indicate need for further assessment / intervention.

16. Early Recognition & Screening Screening Instruments (4)

17. Early Recognition & Screening What Does AUDIT Measure? Questions 1–3Quantity and frequency of alcohol use Questions 4–6Possible dependence on alcohol Questions 7–10Alcohol-related problems AUDIT Scores:Hazardous levels8–12 Harmful levels >13 Chronic health problems related to harmful patterns of drinking may be evident within about three years The items measure:

18. Early Recognition & Screening Drug Check A quantity and frequency measure of licit, illicit and pharmaceutical drug use Can assist GPs to detect problematic use and indicate areas requiring further investigation Can be used for periodic re-screening Indicates psychosocial and high-risk behaviours With SDS and ‘Readiness to Change’ scales, may assist to motivate change.

19. Early Recognition & Screening Urine Drug Screens Confirm recent use, BUT: –do not identify patterns of use (quantity/frequency) –do not indicate current incapacity resulting from drug use –do not detect problematic use. Carefully consider the need for urine testing – history-taking is generally a more reliable source of information.

20. Early Recognition & Screening Urine Drug Screens Confirm recent use, BUT: –do not identify patterns of use (quantity/frequency) –do not indicate current incapacity resulting from drug use –do not detect problematic use. Carefully consider the need for urine testing – history-taking is generally a more reliable source of information.

21. Early Recognition & Screening Severity of Dependence Scale (SDS) A five-item questionnaire measuring degree of psychological dependence Focuses on: –impaired control of illicit drug use –preoccupation with, and anxiety about, drug use in last 12 months Cut off scores indicating dependence –heroin (5) –amphetamines (>4).

22. Early Recognition & Screening Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) This new tool was recently developed by the World Health Organization (WHO) to enable detection of psychoactive drug use in primary care patients Brief, flexible, and designed to assist primary care workers to identify AOD and conduct brief interventions ASSIST underwent trials in Australia (2003) to establish its validity with brief intervention in primary care.