Clinical Skills
© 2009 University of Sydney
Module Learning Outcomes
To be better able to :
• Engage in a therapeutic relationship
• Make a drug and alcohol assessment by:
– history-taking and
– physical examination
• Provide appropriate advice and brief
intervention for substance use issues
Case study
• Jason, a 36 year old man, presents to your
surgery requesting a medical certificate to cover
today only.
• He went out with friends last night, drank about
15 standard drinks and overslept in the morning.
He felt too hung-over to work.
How would you approach this situation?
What advice should you offer Jason?
Does Jason have evidence of a disease?
Aims of consultation
Engagement
Assessment
Goal Setting
Engagement: the first step
What is engagement?
• Building a working relationship
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showing that you care
building rapport
building trust
working towards mutually acceptable
goals
– analysing any ‘counter-transference’ that
may occur and detaching from any
instinctive feelings, if necessary
Engagement
How to engage people:
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Explain (and provide) confidentiality
Interview individually
Appropriate setting
Flexible approach
Be non-confrontational
Be non-judgmental
Be yourself
Limits of confidentiality
In NSW, we must notify DOCS of:
• Injecting drug users <16 yrs old
– NSPs may not obtain sufficient information
• Children at risk due to carer’s substance abuse
• Homeless age 16+, now need to obtain consent
• Pregnant IDU placing future infant at risk
• Must notify police if knowledge of a serious criminal offence
involving a sentence of 5 years or more.
In NSW, not required to notify:
• IDUs age >16 to DOCS
• 14-16 yr olds generally do not require parental consent for
medical or counselling intervention if they understand the
issues
• Condoms and injecting equipment may be given to anyone
who requests them
Practical suggestions
• Consult DOCS, senior colleague or
Administration for difficult cases
• Keep careful notes concerning decisions
about notification
Overview of assessment
• What is the current status?
– Reason for presentation (including social factors)
– Is there intoxication or withdrawal?
• What is the drug use consumption?
– Currently and in the past
– Patterns and routes of administration
• What are the physical and psychosocial consequences
or coexisting problems?
• Is there a substance use diagnosis?
– Harmful use or dependence
• What is the current motivation for change?
History taking
• Tailored to circumstances
– Comprehensive assessment is not always
necessary or helpful on first contact
– If necessary, can be done over several
sessions
– What do I need to know in this case at this
time?
• Assessment is itself a therapeutic process
– Links substance use to problems, sometimes
for the first time
– Quantifies use, enhances self awareness
For every patient you see…
• Quantified alcohol history
• Quantified smoking history
• High index of suspicion for other
substances
– More detailed questions where indicated
• Where positive history exists
– Assess whether daily intake is increasing
or decreasing and if so, why?
– Assess avenues for intervention to
decrease intake
For a comprehensive drug
and alcohol history
Ask about all the drugs of abuse:
• Tobacco
• Alcohol
• Misuse of prescribed drugs
• Illicit drugs:
– Cannabis
– Stimulants (MDMA, amphetamine,
methamphetamine, cocaine)
– Opioids
– Hallucinogens
What is a standard
drink?
NB: home poured drinks are variable but are approx. 2 standard drinks
Drink-less Program, 2005
Non-standard drinks
Drink-less Program, 2005
Low risk drinking levels
NHMRC Australian guidelines to reduce health
risks from drinking alcohol (2009):
1. For reduced lifetime risk of harm from drinking:
2 standard drinks or less in any 1 day (for healthy men
and women, aged 18 and over)
2. For reduced risk of injury in a drinking occasion:
No more than 4 standard drinks per occasion.
3. For people <18 years of age: safest not to drink
Under 15: Especially important not to drink
Between 15-17: Delay drinking initiation for as long
as possible
4. Pregnant (or planning a pregnancy) or
Breastfeeding: Not drinking is safest option
Reaching a diagnosis
Harmful use
– associated with clear physical or
psychological harm
Dependence
Three or more of the following within the last year
– strong desire to use
– loss of control
– withdrawal
– tolerance
– salience
– use despite harm
International Classification of Diseases 10 (ICD-10)
Physical examination 1:
• Look for signs of intoxication or withdrawal:
– Drowsiness (alcohol, benzodiazepines, opiates)
– Agitation (sedative withdrawal, or stimulant
toxicity)
– Tremor (alcohol, benzodiazepines withdrawal)
– Diaphoresis (alcohol and opioid withdrawal)
– Slurred speech, ataxia (alcohol, benzodiazepine
intoxication)
– Pupils (especially opiates)
– Confusion (e.g. Wernicke’s, DTs) or
stimulant/hallucinogen intoxication/psychosis
Physical examination 2:
Medical complications
• Mental State: sensorium, intoxication, mood,
signs of psychosis
• Vital signs (e.g. fever, tachycardia of alcohol
withdrawal or infectious complications)
• Venepuncture sites / track marks (recent or old)
• Lymphadenopathy
• Liver
• Heart
• Lungs
Old track marks
Where is your patient ‘at’?
What is his/her current motivation?
• What is the presenting problem?
– e.g. sore foot, accommodation?
• Does your patient want to stop or
cut down?
Assessment
‘Readiness to Change’ Model
Pre-contemplation
Relapse
Contemplation
Maintenance
Action
Determination
Prochaska & Di Clemente, 1982, Psychotherapy --- Practice, 19
Principles of management
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Use of evidence-based interventions
Establishing a therapeutic relationship
Motivating the patient towards a goal
Holistic approach
Withdrawal management
(detoxification) if needed
• Relapse prevention
• Harm minimisation
Intervention approaches
• Counselling
– individual
– group
– brief and long-term
• Pharmacotherapy
• Peer support e.g. Alcoholics Anonymous
Early and brief intervention
• An intervention as short as five minutes
can produce a sustained reduction in
consumption
• Early intervention leads to reduced
consumption and related problems
• Targets those at risk of harm, but
typically not dependent
Early and brief intervention
• Proactive, opportunistic detection
• Consists of brief advice or counselling
at the point of detection
• For users not ready to change, may
increase their motivation
• For users wanting to change:
– advising on appropriate goals and
strategies
– support
Early and brief intervention
Why intervene early?
• There are more hazardous and harmful
substance users than dependent users
• Substance users don’t tend to seek help
unless they have advanced problems
• Harder to treat once dependence is
established
• Early intervention is simple, acceptable and
cost-effective
Early and brief intervention
Components of brief intervention
Use ‘FLAGS’:
– Feedback
– Listen
– Advice
– Goals
– Strategies
Bien et al, 1993, Addiction, 88
Early and brief intervention
A good outcome from brief intervention:
• Reduction or cessation of use (even
temporary)
• Starting to think about reducing
• Agreeing to accept referral
Motivational enhancement
therapy
• Aims to increase motivation to change
behaviour
• Emphasizes the patient’s right to choose
• Assumes the responsibility and capability
for change are found within the patient
Motivational enhancement
therapy
5 Key Components:
• Express empathy
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Elicit ambivalence
Elicit self-motivational statements
Display counselling micro-skills
Roll with resistance
Motivational enhancement
therapy
Strategies
• Explore ambivalence
– ‘What’s good about your drug use?’ – minimise, but
validate
– ‘What’s not so good?’ - expand
– Explore discrepancies
– Resolve these through change
• Display counselling micro-skills – e.g. active listening,
supportive counselling that is non-judgmental
• Enhance self-efficacy (the patient’s belief in their ability to
achieve these goals of substance use change)
• Help decision making, through problem solving
• Summarise; make suggestions
Goal-setting
Goals must be:
• Realistic and achievable
• Specific and observable
• Client’s goals rather than those of
others
Goal-setting
Whose goals?
• Patient vs family vs therapist
• short-term vs long-term
• drug-specific vs other health and
lifestyle issues
• Look at the social context
– Spouse told patient to come in,
court-mandate, etc
Harm minimisation as an
interim measure
• Long term abstinence may not be
achievable on the first episode of
treatment
• Prevention of complications may lead to
better health when the decision to stop
drug use is finally taken
What if s/he doesn’t want
to change?
• This is part of the change model (precontemplation)
• Leave the door open for future contact
• Agree to disagree
– Need to accept patient autonomy
• Consider any harm reduction strategies
– Address presenting issue
– Safe injecting or alternative routes e.g. nasally,
orally (long evolutionary history of protection
against pathogens)
– Welfare needs
Why harm reduction?
• Even if we are willing to “write off” such
people, society pays the price via crime,
viral infections, health care costs, legal
costs
• Difficulty of eliminating supply
• Free choice: we can advise on good
habits but not enforce them
• Drug users who want to stop may not be
able to do so (dependence)
Harm reduction
Some examples
• Avoidance of driving when intoxicated
• Safety when intoxicated
• Child protection
• Thiamine in alcohol dependence
• Safe injecting
• What you buy is not always what you
think
• Avoid over-heating, dehydration with
stimulants
Drug-seeking behaviour
• The attempt to obtain prescriptions for
psychoactive drugs by making false or
deliberately exaggerated claims of pain or
distress
• A common and significant problem
• Inability to identify and manage drugseeking patients can make a doctor’s
practice unpleasant and frustrating
• An opportunity for intervention
Presentations of Drug
Seeking
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Pain
Insomnia
Emotional distress
Drug withdrawal
Repeatedly running out of medication
early
• Lost scripts or medication
Clinical Features
• Ask for their drug of choice by name
• Unlikely story e.g. forgot to bring
medication on vacation
• Refuse all other therapeutic options
• Make it difficult to confirm their story e.g.
present after hours &/or weekend
• Going to multiple doctors
• May present with signs of intoxication
Drugs sought
• Commonly – benzodiazepines, opioids
• Less commonly – other sedatives,
stimulants, anticholinergics
Assessment When Drug
Seeking is Suspected
• Take an alcohol and drug history
• Patients with a current or past history of
dependence on other drugs are at greater
risk for opioid &/or benzodiazepine
dependence.
• Examine for signs of intoxication or
withdrawal
• Examine for track marks in antecubital
fossae, lower legs, neck
Confirmation Possibilities
• Previous doctors, hospital(s)
• Medicare Australia Prescription Shopping
Information Service - 1 800 631 181
– Doctor needs to apply for an “access number”
– With patient consent detailed reports available
• NSW Pharmaceutical Services Branch 02 9879 5239
• Other people if appropriate
Diagnosis
• Is the person dependent?
• Is the person drug seeking?
• Is the person currently on an opioid
treatment program?
• What is plan of management?
• Do you refuse to prescribe or not and
under what conditions?
Management
• Discuss openly with the patient if you
believe they are drug dependent and
why you think they’ve come
• Offer help and treatment for their
problems as indicated
Saying ‘no’
• Empathise but be firm
• Make it clear early on that there are
limits on what you are prepared to do
• Say ‘no’ early on to an inappropriate
request e.g. “I don’t prescribe benzos
to patients I don’t know”
• Give reasons for your decisions and
plan of management, offer pt some
alternative (eg refer to ED).
If you are going to
prescribe …
• Small amounts and safe supply
• Form contract including what happens
if management is not adhered to
• Ensure Medication is part of an
appropriate and comprehensive
management plan.
• Regular follow up
• For OTP patients, refer back to their
prescriber / treatment centre
Managing difficult
behaviour
• Set clear limits. Can refer to practice / hospital
policies
• You have the right to say ‘no’ e.g. scripts for
benzos, inappropriate medical certificates
• Have good security available for staff, other
patients, money, prescription pads
• Stay calm and don’t respond emotionally
• Judicious use of ‘carrot and stick’ approach
• If risk of violence, give way to the patient and call
security or police when you can.
Maintaining a positive
attitude
• Treatment is a process, not an event,
meaning that it may take some time for a
patient to cope in a certain situation.
• The course of substance use is often
similar to that of a chronic relapsing
disease
• Those who abuse substances have a right
to professional assistance and a fair
hearing.
Project CREATE
Kahan et al, 2001, Subst Abus, 22
Self-test case
John is a 34 year old man who presents to the
emergency department with painful lump in his
right cubital fossa. On physical examination
you find an abscess on the right cubital fossa,
and track marks on the left. He admits to
heroin use.
• How would you respond to this patient?
• Do you have a role in addressing his drug use?
• How would you assess and manage him?
Self-test answers
• Response to patient
– Non-judgmental assessment
• Medical role involves:
– Assessment, treatment of abscess or
other complications, referral ,
consideration of pharmacotherapy
• Assess as per earlier slides
• Management
– Antibiotics, drainage, pharmacotherapy,
counselling
Revisiting initial case study
• Jason, a 36 year old man, presents to your
surgery requesting a medical certificate to
cover today only.
• He went out with friends last night, drank
about 15 standard drinks and overslept in the
morning. He felt too hung-over to work.
How would you approach this situation?
What advice should you offer Jason?
Does Jason have evidence of a disease?
Revisiting initial case study
• Approach by assessment
• Response depends on assessment
findings. Brief intervention? Can we
prevent this from recurring?
• Hangover or persisting intoxication?
Medical disorders? A work certificate
may be appropriate.
Contributors
• Associate Professor Kate Conigrave
Staff Specialist, Drug Health Services, RPAH
Associate Professor, Medicine and School of Public Health, University
of Sydney
• Dr Ken Curry
Medical Director, Drug Health Services, Canterbury Hospital
Clinical Senior Lecturer, University of Sydney
• Professor Paul Haber
Staff Specialist, Head of Department, Drug Health Services, RPAH
Conjoint Professor in Medicine, University of Sydney
All images used with permission, where applicable