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Challenging Behaviours Challenging Behaviours Patients Seeking Medications: Your Experiences Describe a situation where a patient requested medications you believed were not justified from a clinical perspective (i.e., you thought they were ‘drug-seeking’). • Describe the scenario • How did you feel? • How did you respond? • How did the patient respond? • What was the outcome? • What would you do next time? • What protocols are there to assist you and other staff to respond to future situations? Challenging Behaviours Managing Challenging Situations • Every general practice should have relevant protocols in place to meet clinical, ethical and legal requirements and patient demands • There are inherent difficulties for GPs associated with: • patients who appear determined to obtain drugs through inappropriate means or behaviours (or ‘doctor shoppers’, in the absence of better expression) • patients or others who are intoxicated • patient behaviours that are incongruent with the agreed treatment plan. Challenging Behaviours Principles of Management • Safety (patient, self, staff, other patients) • Prevent temptation (hide prescription pads / sample medications, anything of value, etc.) • Advise patient of obligations & limitations of prescribing regulations in your jurisdiction • Offer alternatives rather than refuse treatment (p.r.n.) • If necessary, contact the police and/or jurisdictional Health Department • Restrict harm by limiting number and dose of medications prescribed. Challenging Behaviours Patients Seeking Medications (1) • May give you a seemingly ‘well-rehearsed’ scenario describing e.g., insomnia, stress, alcohol withdrawal • May be familiar with drug names (though may mispronounce them) • May request specific drugs and quantities (and be aware of specific drug actions) • May express reservations about alternatives (esp. non-drug alternatives) • May seek analgesics for ‘difficult to assess’ pain. Challenging Behaviours Patients Seeking Medications (2) • May be increasingly anxious or agitated if sensing your reluctance to prescribe • May have other significant drug use patterns or related problems (e.g., already prescribed therapeutic dose) • May punish or reward the GP according to response • May complain of opioid (or other) allergy or side effects to suggested medications (esp. if seeking Pethidine by injection). Challenging Behaviours Responses to ‘Drug-Seeking’ Behaviour (1) • Ensure safety • Offer comprehensive assessment (for pain or other ailment) incl. physical examination, AOD history/existing dependence • Don’t prescribe on first visit • Say ‘no’ to scripts but offer appropriate medical advice • Offer information regarding harm minimisation strategies • Offer assistance (when required) or referral for drugrelated issues. Challenging Behaviours Responses to ‘Drug-Seeking’ Behaviour (2) If the GP decides to prescribe: • restrict harm potential by limiting number and dose of medications prescribed • prescribe NSAIDs or other non-opioids • if BZDs indicated, prescribe long acting forms, time limited, in small quantities • decrease prescribing or dispensing periods • negotiate alternative stress / anxiety or insomnia treatments while drug use is being phased out • monitor for transfer of dependence to other drugs. Challenging Behaviours What concerns may GPs have regarding ‘drug-seeking’ behaviour in the General Practice setting? How can GPs plan for future situations, and ensure an appropriate and consistent response? Challenging Behaviours Intoxicated Behaviours Include: • Poor memory and retention • Poor attention, concentration or gaps in understanding • Slurred speech • Disinhibition and mood swings (unpredictable) • Inappropriate or poor reactions to verbal instruction or commands • Poor judgment, confusion, frustration. Challenging Behaviours Misdiagnosis Intoxicated behaviours may mimic a range of other conditions such as: • concussion (confusion, disorientation) • CVA / tumour • hypoxia • dehydration • shock • diabetes • septicaemia • UTI • post-ictal confusion. Challenging Behaviours Responding to Intoxication (1) Assess and Examine • AOD history (e.g., pattern, quantity and recency of last use) • physical exam (for other possible conditions) • avoid a prolonged consultation • do not make final decisions on treatment options (they may not remember) • ask about suicidal ideation / plans (referral may be required) • explore options for sobering up and/or drug withdrawal. Observe • is presentation consistent with reported use? (exclude any physical complications) • if intoxication does not resolve within expected time frame, something else is happening! Challenging Behaviours Responding to Intoxication (2) Respond • avoid psychoactive medication • avoid anything requiring consent, if possible • consider ethical and legal consequences of sending an intoxicated person away (e.g., if driving) • if appropriate, refer home or to a designated place for observation • use harm minimisation approaches. Arrange • a safe means of getting ‘home’ or to a place for observation • for review/follow-up. Challenging Behaviours Communicating the Role of the GP to the Patient • AOD issues are health problems, not moral or ethical issues • A clear and non-judgmental approach assists in building and developing rapport with all patients • A quality assessment includes ensuring an understanding of the patient’s issues, and the patient’s perspective on life • Whatever a patient’s circumstances, a recent history should be part of routine clinical assessment • Communicate clearly your role, what you need to know to help your patient, and why you are asking about AOD issues • Set limits – be clear about what you can and can’t do • Listen to the patient’s concerns, and his or her requests without prejudice. Challenging Behaviours Effective Communication when Patients are Feeling Defensive • Remain calm • If the patient becomes angry or aggressive: • demonstrate calm control, avoid becoming emotional • keep your voice low • sit, or stand, side-on to the patient • use the patient’s name • acknowledge the patient’s feelings, and encourage the patient to take control of his or her emotions • Safety – scan the room in case you need a quick exit. Challenging Behaviours The Patient’s Perspective What would be your response if the patient said... • ‘GPs are patronising or antagonistic, so they earn their dislike, distrust, or anger’ • ‘GPs can make you feel humiliated and manipulated’ • ‘GPs make you comply with unrealistic treatment regimes’ • ‘GPs don’t understand what it is that I need, so I have to behave in a way to ensure my needs are met’ • ‘GPs don’t understand that ‘it’ is needed now!’ Challenging Behaviours A Balancing Act • All patients, regardless of their behaviours, have legitimate needs that should be addressed • Offer some negotiated treatment within a harm minimisation framework so their needs are at least partially met • Do not meet patient requests when to do so is potentially harmful • Share the care with AOD specialist agencies whenever possible. Challenging Behaviours