Drug and Alcohol Use Assessment: A Comprehensive Guide for Nurses and Midwives

4: Drug and Alcohol use Prepared byJ. Mabbutt & C. MaynardNaMO September 2008

4: Drug and Alcohol use assessment: Objectives 1. By the end of the session nurses & midwives will have an increase in their knowledge & skills to enable them to take a basic drug & alcohol use history & also to be aware of the broad issues regarding a thorough assessment 2. During the session nurses & midwives will participate in teaching activities to improve their ability to complete a basic drug and alcohol use history & increase their knowledge regarding a thorough assessment

4: Drug and Alcohol use assessment (1) Nurses & midwives are well placed to assess, manage and intervene with someone’s drug & alcohol use It is essential that nurses and midwives are well-equipped to identify presentations that require admission, treatment, referral or further investigation Refer to NSW Health Policy, 2007 – “Nursing and Midwifery Management of Drug and Alcohol Issues in the Delivery of Health Care” for further information

4: Drug and Alcohol use assessment (2) A drug & alcohol use assessment is important in order to: Establish a correct diagnosis Predict the effects of intoxication, assess its life-threatening potential, & plan appropriate intervention Assess the possibility of drug interaction between the drug taken by the patient and drug(s) administered by the nurse, or between those already taken

4: Drug and Alcohol use assessment (3) Predict the possibility of withdrawal Assess risk behaviours, including self harm Ensure duty of care Gain an understanding of the patient as a whole person, not merely in terms of their symptoms Select appropriate therapeutic interventions

4: Drug and Alcohol use assessment (4) Some diagnoses may be confused with alcohol or drug intoxication or withdrawal This can lead to significant medical problems being missed if the nurse or midwife does not look for causes beyond alcohol or drugs Such problems include infection, hypoxia, hypoglycaemia and other metabolic imbalances, head injury, CVA, liver disease, drug overdose and psychosis

4: General principles of Drug & Alcohol use assessment • A systematic drug & alcohol use assessment of all patients, quantified & documented, including a thorough examination of: • indicators of risk • past medical history • psychosocial issues • physical signs & symptoms • mental health status & pathology results • No single sign, symptom or pathology test is conclusive evidence of an alcohol or drug-related issue

4: Key elements of assessment (1) The following key elements must be clarified with each patient as part of an assessment: • Type of drug (See Appendix 6 for street names) • Route of administration • Frequency of use • Dose & duration of use • Time & amount of the last dose, e.g. grams of alcohol or number of standard drinks, mls and mgs of methadone, grams of cannabis, etc

4: Key elements of assessment (2) • NOTE: It is important to ask the person if they are using more than one drug at a time, as polydrug use can significantly increase the risk involved

4: Quantifying substance use (1) • A person’s drug & alcohol use must be quantified, & include both prescribed & non-prescribed drugs • Determine whether the level of use may cause harm, and whether withdrawal or progression to overdose is imminent • For some substances such as alcohol, there is an agreed low risk level of consumption • For tobacco there is no safe level of consumption

4: Quantifying substance use (2) • Illicit drugs are difficult to quantify because the same drug can differ vastly from dose to dose in terms of purity & actual ingredients. • Nevertheless, for illicit drugs, document e.g. the number of injections, bongs, or the dollar cost or amount used (e.g. grams) • Many medications should only be taken if they are on prescription & in the way prescribed

4: Confidentiality • Explain the patient’s right to privacy & any limits to confidentiality, e.g. if there are child protection issues • Patients need to be informed that the purpose of taking a drug & alcohol history is to obtain information that is relevant to their health / nota forensic investigation. • Information in most cases, can only be provided to third parties with written permission • Exceptions, for example, if the person is homicidal or suicidal; if there are current child protection issues or if a subpoena has been issued for the patient’s notes

4: Signs of drug & alcohol use administration: Some examples • Smell of alcohol • Signs of alcohol use (see alcohol withdrawal presentation) • Puncture marks • Cellulitis/phlebitis • Skin abscesses • erosion or irritation around nostrils/septum • Irritation or rash around nose and mouth

4: Signs of withdrawalSome examples • Sweating • Tremor • Agitation • Disturbance of coordination, gait • Gooseflesh • Dilated pupils • Leg, stomach cramps

4: Consequences of use • Excessive weight loss, signs of numerous old injuries, e.g. bruising • General physical health problems such as septicaemia, HIV, hepatitis B/C, jaundice • Mental health illness, treatment, involuntary admissions • Psychological distress/needing to do sex work/victim of rape/violence • Crime, jail, stealing from family & friends, selling possessions • Loss of relationships, employment, housing, savings etc

4: Mental Status Examination (1) • Appearance & behaviour • Speech • Mood • Affect • Thought form; Thought content • Perception • Insight & Judgment

4: Mental Status Examination (2) • All health staff need to complete a preliminary screening for suicide risk as part of any assessment • Refer to NSW Health Department Policy PD2005_121 ‘Management of patients with possible suicidal behaviour.’ (there is also a CD-ROM resource for Mental Health and Non Mental Health Workers) • Refer also to NSW Mental Health Outcomes & Assessment Training Project (MH-OAT) developed to improve assessment skills for mental health staff

HIV, Hepatitis B & C Screening, Child Protection & Domestic Violence Issues • Besides the information that has been presented so far that needs to be collected on admission, there is some other important information to assess • The next slides cover three of a number important issues that should be part of an assessment • Child Protection & Domestic Violence screening are mandatory • HIV, Hepatitis B & C screening should also be part of any assessment, especially that hepatitis B is vaccine preventable and the high rate of Hepatitis C in injecting drug users

4.8 HIV, Hepatitis B & C Screening • Hepatitis C is a major public health concern in Australia • Offer all patients screening for HIV, hepatitis B & C & advise on the availability of hepatitis B vaccination • Pre-test and post-test counselling must be provided as outlined in: NSW Health Policy Directive PD2005_048: Counselling associated with HIV antibody testing – guidelines. • For further information, see ‘Nurses & Hepatitis C’ – Australasian Society for HIV Medicine (ASHM) http://www.ashm.org.au/uploads/File/nurses-supp.pdf

4.9 Child Protection Issues (1) • Health care workers have a duty under the NSW Children and Young Persons (Care and Protection) Act 1998to notify the Department of Community Services whenever they suspect that a child or young person may be at risk of harm through abuse or neglect • It is important to note that drug & alcohol issue by a parent does not automatically equate to a child or young person being at risk • For further information, refer to: NSW Health Policy Directive PD2005_299. Protecting children and young people • NSW Health Frontline Procedures for the protection of children and young people. 2000

4.9 Child Protection Issues (2) • Pregnant opioid-dependent women should always be referred to Drug Use in Pregnancy Services • For further information, refer to the National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. (March 2006)http://www.health.nsw.gov.au/pubs/2006/ncg_druguse.html • NSW Health Neonatal Abstinence Syndrome (NAS) Guidelines, 2005 focus on care of opioid dependant women and care of the newborn from a child protection perspective http://www.health.nsw.gov.au/policies/pd/2005/PD2005_494.html

4: Domestic violence issues • Amongst those with drug & alcohol issues are significant numbers of both victims and perpetrators of domestic violence. Responding to this group presents particular challenges for nurses • For further information about the management of domestic violence and assessment of risk, refer to: • NSW Health Policy for Identifying and Responding to Domestic Violence, 2003 • NSW Health Policy Directive PD2006_084. Identifying and responding to domestic violence

4: Hints on taking a drug & alcohol history (1) Here are some points to remember when taking a history: • Normalise the assessment by telling the patient that you ask these questions to all patients • Try to make the environment as quiet and private as possible • Be mindful of the patient’s level of physical & emotional comfort • Note inconsistencies in what the patient tells you

4: Hints on taking a drug & alcohol history (2) • If a question angers the patient, leave it until later when you can rephrase the question • A history of the person’s drug and alcohol use can also be elicited from their spouse, friends or family, with the patients consent • Examine hospital medical records and speak to other health workers to gain supporting information for your history

4: Hints on taking a drug & alcohol history (3) • When discussing drug & alcohol issues try to remain as non-threatening and non-judgmental as possible The following techniques may help, but be mindful that they may not be suitable for every patient. Use discretion and professional judgment as to which may be useful • Introduce drinking/drug use as a normal, everyday experience, e.g. “What do you like to drink each day? • Ask about frequency of use e.g. “how often would you have a drink/use heroin/cannabis?” or ask “what is a typical day of drug use?”

4: Hints on taking a drug & alcohol history (4) • Use open-ended questions, e.g. “How has your drinking/drug use changed over time?” • Try reflective listening, e.g. “Sounds like your drinking has been causing you problems lately” • Do not be distracted away from important points • Do not allow personal attitudes to affect the assessment • Be affirmative, e.g. “It takes a lot of courage to open up and talk about your drug use”

4: Hints on taking a drug & alcohol history (5) • Be sensitive to the patient’s cultural background & language • Suggest high levels of drug and alcohol use, e.g. “How much would you normally drink in a session? Twenty schooners?” • However, when talking with adolescents, be careful that they do not perceive the overestimated amount as an expected figure, thereby encouraging them to exaggerate it further

4: Hints on taking a drug & alcohol history (6) • Summarise, e.g. “On the one hand you like drinking because it helps you to relax but on the other hand you’re concerned about the effect it will have on the kids.” • Do not assume that the patient perceives their drug & alcohol use as a problem • If you don’t understand the jargon, ask the patient to explain • See a following slide for street names of drugs

4: Quantifying substance use Don’t be afraid to ask • Even ‘experts’ in the drug & alcohol field, may not know a street drug name • So, don’t be afraid to ask about the name, what another name is used for the drug, how it effects the person • By asking these questions you should be able to have a good idea what type of drug it is, by not asking you are not completing an assessment! • Surprisingly, drug uses will volunteer a lot of information about drugs to people who come across as interested, wanting to help & not judgmental – so ask!

4: Appendix 6: Street names of drugs * Adapted from the Illicit Drug Data Report. 2004–05 Australian Crime Commission * Adapted from the Illicit Drug Data Report. 2004–05 Australian Crime Commission

4: Appendix 6: Street names of drugs * Adapted from the Illicit Drug Data Report. 2004–05 Australian Crime Commission

4: Assessment – Activity 3: Low risk – high risk Admission game 1. Handout cards with scenarios to participants (distribute) all cards (or use projector) 2. Lay the risk plates (4) across the floor 3. One participant reads out their card (or takes it in turn via the projector), then places it (or indicates which of the risk plates it relates to) on a risk plates. They are asked to explain why on that plate. They may fill in the gaps in the scenario to justify their decision. The group may assist. 4. A second participant continues this process until all scenarios are completed the time allocated is over. RPA Education Unit CSAHS – Powell, Keen & Brown 1994

4: Assessment – Activity 4:Admission role play activity (1) 1. One nurse, patient and observer 2. The setting is on the ward 1 hour after admission 3. The patient is given a role play card which is not shown to the nurse, but the patient tells the nurse the reason for the admission. The nurse asks the patient about their substance use history. If this is a local substance use assessment tool is it recorded on that or just on a piece of paper in a systematic way, one at a time. 4. The observers only record information for constructive feedback. RPA Education Unit CSAHS – Powell, Keen & Brown 1994

4: Assessment Admission role play activity 4 (2) 5. Patients are not to overact and should make it fairly easy for the nurse! 6. At the end of the time period the nurse and patient swap chairs. The nurse debriefs about what the experience was like, then is followed by the patient and the observer. 7. The nurse can now look at the role play card to see how accurate they were in the assessment • This is not a test, just practice, so relax! Developed by Mabbutt 2003

4: Assessment Admission role play activity 4 (3) • The following key elements must be clarified with each patient as part of an assessment. Use these questions in the role play: • Type of drug (See Appendix 6 for street names) • Route of administration • Frequency of use • Dose & duration of use • Time & amount of the last dose, e.g. grams of alcohol or number of standard drinks, mls & mgs of methadone, grams of cannabis, etc

4: AssessmentQuantifying an alcohol history Show either of the videos below from the CIWAR-Ar CD- ROM and discuss • E3 Early detection of people at risk (alcohol) (9.04 min) • E4 Quantifying an alcohol history & Brief intervention using the AUDIT & Drinkless Resource (6.18 min) • See Opportunistic Intervention presentation No 5 for more details on the use of the AUDIT and Intervention re alcohol use

Drug and Alcohol Use Assessment: A Comprehensive Guide for Nurses and Midwives