Download No Slide Title

Early Recognition
& Screening
Early Recognition & Screening
Early Recognition of
Problematic AOD Use
• Many people who use illicit drugs are reluctant
to reveal their use or related problems
• A professional empathetic approach (open,
non-judgmental) will assist to build rapport, to
elicit an accurate AOD history
• A range of indicators (medical, behavioural or
psychosocial) may prompt further investigation.
Early Recognition & Screening
Medical Indicators of
Problematic AOD Use
Drug-related complications
– side effects
(e.g., constipation,
hallucinations)
– overdose
(e.g., respiratory
depression)
– withdrawal
(e.g., irritability,
depression)
– foreign body injection
(e.g., CVA, endocarditis)
Route-specific
– smoking (asthma,
respiratory problems)
– injecting (poor venous
access, cellulitis)
– intranasal (nasal septal
damage, rhinnorhoea)
General health
– anaemia, poor nutrition
or dental hygiene,
weight loss, loss of libido
Sharing injecting equipment
– BBV
Early Recognition & Screening
Behavioural Indicators of
Problematic AOD Use
•
•
•
•
•
•
•
•
•
•
Presenting after hours
Multiple presentations for painful conditions
Use of medical terminology
Loss of scripts or medication / requests for specific drugs
Changed physical appearance over time
(change in grooming)
 job/school performance, missed appointments
Trauma, poor concentration
Conflicts with others
Intolerant or ‘allergic’ to suggested alternatives
Specific withdrawal symptoms.
Early Recognition & Screening
Psychosocial Indicators of
Problematic AOD Use
• Multiple medical contacts
• Many contacts with Emergency Departments
• Depression
• Family history of problematic AOD use
• Partner who uses alcohol or other drugs
• Psychiatric treatment
• Young age or adolescent – withdrawal from school,
friends, family
• Generally  social functioning.
Early Recognition & Screening
GPs Are Well Placed to
Detect AOD Issues Because...
 85% of people visit a GP at least yearly
 GPs and PHC professionals are usually first point of
contact with the health care system
 GPs are ideally placed to link prevention with
comprehensive, continuing, and holistic care
 GPs provide services spanning the health care
continuum, from illness prevention to treatment and
rehabilitation
 Patients expect GPs to:
 provide lifestyle advice
 ask about their use of AOD.
Early Recognition & Screening
Screening
• Commonly performed in health settings
• Generally well accepted
• Detects the likelihood of need for diagnosis, and
informs need for further investigation
• Screening instruments specific to AOD use:
– can suggest a diagnosis / indicate
problematic use
– allow for a simple (often self-report)
approach to information gathering.
Early Recognition & Screening
AOD Issues Are Often Missed
Because…
• AOD issues are difficult to detect
• GPs unsure how to respond, or if they should
• Symptoms may mimic other conditions
• Inadequate role models or role support for GPs
• GPs are embarrassed to ask, concerned about patient
evasion, or unsure about treatment effectiveness
• GPs perceive AOD is the domain of ‘specialists’.
Early Recognition & Screening
Routine AOD Screening is
Appropriate for...
• General hospital patients
– esp. liver, neurological, cardiovascular disorders,
MVA / trauma
• ED/casualty presentations
• People who are depressed / suicidal, or have mental
health problems
• General Practice patients
• Special groups (e.g., homeless, prisoners)
• People with AOD-related legal offences (e.g., DUI).
Early Recognition & Screening
Benefits of Screening
• Informs diagnosis
• Provides opportunity for education
• Alerts GP to risks for interactions with
medications or other aspects of treatment
• Offers opportunities to engage
• For people not dependent, screening has
proved beneficial in reducing high-risk
activities.
Early Recognition & Screening
Who Should Be Screened?
• All new patients
• Patients with chronic problems
• Patients with acute problems
• Patients seeking pre-conception and
antenatal care.
Note: Enhanced Primary Care
Medicare Benefit Schedule items.
Early Recognition & Screening
To Improve Detection
Use:
• routine inquiry
• screening questionnaires
– e.g., CAGE / AUDIT
• biological screening (pathology tests)
– e.g., blood, liver function, hep B and C serology,
urine
• knowledge of common indicators and clinical
presentations consistent with problematic use.
In General Practice, AOD issues are often missed
amongst women, the elderly and among people who
are not ready to address high-risk use.
Early Recognition & Screening
Screening Instruments (1)
1 To screen for, and identify, problematic AOD use
– e.g., AUDIT
2 To identify frequency and quantity of use
– e.g., DrugCheck
– useful for diagnostic purposes and establishing
treatment goals
3 To assess for severity of dependence
– e.g., SDS
– sensitive to dependence and for monitoring over
time
– not sensitive to low-level problematic use.
Early Recognition & Screening
Screening Instruments (2)
Biochemical measures:
– e.g., urine, bloods
– usually expensive and insensitive
– useful if validation of recent use is required
– like quantity / frequency measures, fail to
provide information on psychosocial impact
of drug use
Screening tools cannot replace
a clinical interview!
Early Recognition & Screening
Screening Instruments (3)
• Should be selected for specific purposes:
– few tools have cross-cultural applicability
– should be used according to patient’s
capacity for completion
– consider the role of the tool in informing
treatment
• Ideally, have been appropriately validated
• Usually provide cheap, instant results
• Indicate need for further assessment /
intervention.
Early Recognition & Screening
Screening Instruments (4)
Test/Tool
 Breathalyser
 Bloods/
LFTs
Advantages




Immediate results
Accurate
Identifies recent drinking
Help relate health problems to drinking
patterns
Disadvantages




 CAGE




 AUDIT




Short
Can be used in interview or self-report
No special tools required
Identifies hazardous/harmful drinking
patterns
Focuses on recent use, identifies patterns
Can identify best intervention
Accurate, cross-culturally validated
For administration or self-report


Machine expensive
Unable to assess for problematic
drinking
Specific only to liver disease, not
patterns of drinking
Less sensitive than clinical
judgement
Insensitive to low-level
problematic drinking patterns
Require copy of tool and
interpretation information
Early Recognition & Screening
What Does AUDIT Measure?
The items measure:
Questions 1–3
Quantity and frequency of alcohol use
Questions 4–6
Possible dependence on alcohol
Questions 7–10 Alcohol-related problems
AUDIT Scores:
Hazardous levels
Harmful levels
8–12
>13
Chronic health problems related to harmful patterns of drinking
may be evident within about three years
Early Recognition & Screening
Drug Check
• A quantity and frequency measure of licit, illicit
and pharmaceutical drug use
• Can assist GPs to detect problematic use and
indicate areas requiring further investigation
• Can be used for periodic re-screening
• Indicates psychosocial and high-risk
behaviours
• With SDS and ‘Readiness to Change’ scales,
may assist to motivate change.
Early Recognition & Screening
Urine Drug Screens
Confirm recent use, BUT:
– do not identify patterns of use
(quantity/frequency)
– do not indicate current incapacity resulting
from drug use
– do not detect problematic use.
Carefully consider the need for urine testing –
history-taking is generally a more reliable source
of information.
Early Recognition & Screening
Severity of Dependence Scale
(SDS)
• A five-item questionnaire measuring degree of
psychological dependence
• Focuses on:
– impaired control of illicit drug use
– preoccupation with, and anxiety about, drug use in
last 12 months
• Cut off scores indicating dependence
– heroin (5)
– amphetamines (>4).
Early Recognition & Screening
Alcohol, Smoking, and Substance
Involvement Screening Test
(ASSIST)
• This new tool was recently developed by the World
Health Organization (WHO) to enable detection of
psychoactive drug use in primary care patients
• Brief, flexible, and designed to assist primary care
workers to identify AOD and conduct brief interventions
• ASSIST underwent trials in Australia (2003) to establish
its validity with brief intervention in primary care.
Early Recognition & Screening