1. September 2015 COMMUNICATION AND SUBSTANCE MISUSE: THE BRIDGE BETWEEN ASSESSMENT AND TREATMENT

2.  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

3.  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

4.  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

5.  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

6.  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

7.  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

8.  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

9.  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?

10.  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

11.  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

12.  ASK – routinely question and record information  ASSESS – comprehensive history  ADVISE – brief intervention  ASSIST – cognitive behavioural  ARRANGE - admission

13.  Ask all patients – record the findings  Style is a powerful determinant  Awareness and sensitivity of ambivalence  Non-judgemental  Non-confrontational style

14.  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

15.  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

16.  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

17.  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

18.  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

19.  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

20.  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

21.  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

22.  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

23. Bien TH, Miller WR, Tonigan JS (1993) Brief interventions for alcohol problems: a review. Addiction 88:315-35 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