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COMMUNICATION AND SUBSTANCE MISUSE: THE BRIDGE BETWEEN ASSESSMENT AND TREATMENT March 2016 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 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 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 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 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 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 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 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? 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 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 ASK – routinely question and record information ASSESS – comprehensive history ADVISE – brief intervention ASSIST – cognitive behavioural ARRANGE - admission Ask all patients – record the findings Style is a powerful determinant Awareness and sensitivity of ambivalence Non-judgemental Non-confrontational style 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 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 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 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 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 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 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 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 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 Bien TH, Miller WR, Tonigan JS (1993) Brief interventions for alcohol problems: a review. Addiction 88:315-35 Dunlop, A., Perry, N. and Robinson ,M. (2015) ‘ Therapeutic Relationship’, in Haber, P. Day, C. and Farrell, M. (ed) Addiction Medicine Principles and Practice, Australia, IP Communications, pp104-113 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
