COMMUNICATION AND SUBSTANCE MISUSE: THE BRIDGE BETWEEN ASSESSMENT AND TREATMENT

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

2. LEARNING OUTCOMES • 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. INTRODUCTION – distinctive features • 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. DISTINCTIVE FEATURES • 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. BARRIERS • 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. ASSESSMENT (CROSS REFERENCE) • 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. COMPONENTS OF EFFECTIVE COMMUNICATION • 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. INTRODUCTIONS AND RAPPORT BUILDING • 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. ELICIT CHANGE TALK • 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. ACTIVE LISTENING & POSITIVE RELATIONSHIP • 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. CONSIDER CRITICAL ISSUES • 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. ASSESSMENT PROCESS • ASK – routinely question and record information • ASSESS – comprehensive history • ADVISE – brief intervention • ASSIST – cognitive behavioural • ARRANGE - admission

13. 1 ASK – TAKE A PROPER HISTORY • Ask all patients – record the findings • Style is a powerful determinant • Awareness and sensitivity of ambivalence • Non-judgemental • Non-confrontational style

14. 2 ASSESS • 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. 3 ADVISE: BRIEF INTERVENTION • 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. 4 ASSIST • 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. ‘FRAMES’ model of brief intervention (Miller & Sanchez 1994) • 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. 5 ADMISSION – WHEN AND WHERE? • 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. OBJECTIVES • 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. TREATMENT AIMS • 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. TREATMENT AIMS • Prevention of complications e.g. vitamin supplementation: Wernicke Korsakoff’s syndrome Thiamine • Relapse prevention e.g. Acamprosate, naltrexone, disulfiram • Block pleasant effects: naltrexone • Reduce craving: acamprosate • 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. ISSUES • 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. References 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