Assessment as an intervention

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Assessment
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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 charge.

What are the key issues? How might you respond?
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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
Sarahs priorities? How might you respond?
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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.

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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.

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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)
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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)
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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.

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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.

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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.
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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.

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Key Questions

• How will undertaking an AOD assessment make a
  difference to your practice?
• What are the barriers to assessing a patients
  use of psychoactive drugs?

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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.

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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?

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A Patients 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.

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AOD History

• The GP needs to ask about
• type of drug/s used
• pattern of use (duration, quantity, frequency of
  use, last 13 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).

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AOD History The Last 24 Hours

• Obtain information about the quantity
  andfrequency 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 patients help, from value to weight.

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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).

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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.

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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.

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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?
  

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Types of Problems

• Different patterns of drug use result in
  different types of problems.
• Drug use may affect all areas of a patients life
  and problems are not restricted to dependent drug
  use.

Regular/ Excessive Use health finances relationshi
ps
Intoxication accidents/injury poisoning/hangovers
absenteeism high-risk behaviour
Dependence impaired control drug-centred
behaviour severe problems withdrawal
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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.

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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).

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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?

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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.

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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.

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Treatment Plan

• Identify
• whether the patient exhibits tolerance, or signs
  of dependence
• patients 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?

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Treatment Matching for AOD in General Practice
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GP Treatment Options
Assessment