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Clinical Framework Clinical Framework

Troy, an 18 year old, has recently presented twice on Tuesday mornings requesting a Troy, an 18 year old, has recently presented twice on Tuesday mornings requesting a sick certificate for the day before for seemingly ‘thin’ reasons, following a ‘heavy’ weekend. • You probably need to find out more…. . • Could drugs be involved in any way? • How do you start? Clinical Framework

Key Considerations • Individual patient issues • Patterns of drug use • ? Associated Key Considerations • Individual patient issues • Patterns of drug use • ? Associated problems • ? Dependence • ? Associated behaviours Clinical Framework

Identifying and Responding to AOD Problems Non-problematic, low risk use Risky or high risk Identifying and Responding to AOD Problems Non-problematic, low risk use Risky or high risk use Dependence The severity of the problem determines treatment goals and treatment options. No major lifestyle disruptions, and not dependent • Most commonly seen group in GP setting. May present with unrelated complaint e. g. hangovers, school/work problems, drink driving charges, MVA, poor sleep or depression • Detected by GP asking lifestyle question. • Great potential for GP intervention with high likelihood of ‘success’. Major lifestyle disruption, significant dependence • Easier to detect but less easy to change. May take many attempts to achieve goal. • May be associated with challenging behaviour. Clinical Framework

Types of Problems Different patterns of drug use result in different types of problems. Types of Problems Different patterns of drug use result in different types of problems. Drug use may affect all areas of a patient’s life and problems are not restricted to dependent drug use. Intoxication accidents / injury poisoning / hangovers absenteeism high risk behaviour I R D Regular / excessive Use health finances relationships child neglect Dependence impaired control drug-centred behaviour anxiety / isolation / social problems withdrawal Clinical Framework

Types of Problems (RU) Intoxication Regular Vein damage Use · Infections Organ Disease Relationships Types of Problems (RU) Intoxication Regular Vein damage Use · Infections Organ Disease Relationships Financial Clinical Framework

Types of Problems (D) Intoxication Regular Use Dependence · Withdrawal Craving Obsessive Cognitive Conflict Types of Problems (D) Intoxication Regular Use Dependence · Withdrawal Craving Obsessive Cognitive Conflict Loss of Control Clinical Framework

Types of Problems: Clinical Samples Intox. Dependence Regular Use Clinical Framework Types of Problems: Clinical Samples Intox. Dependence Regular Use Clinical Framework

How Do You Start? Consider using open-ended questions such as: ‘Are you healthy and How Do You Start? Consider using open-ended questions such as: ‘Are you healthy and well? Do you eat well? Do you exercise? Even commonly used drugs can affect our health. Do you smoke? What about cannabis? Do you use pills? Do you inject? Take anything else? ’ You may need to clarify quantities, frequency, context of use etc. Clinical Framework

Troy’s Response - 1 Troy says he only drinks at weekends when he often Troy’s Response - 1 Troy says he only drinks at weekends when he often goes to parties. He tells you he drinks 6 cans of Jack Daniels most Saturdays and uses one or two ecstasy tablets about once a month. This last weekend he drank a bit more - about double his usual amount and consequently was ‘hung-over’ on Monday. How could you respond? Is it worth trying to find out more? What might Troy think about your response? Is he likely to change? Clinical Framework

Troy’s Response - 2 Troy says he usually drinks about half a bottle of Troy’s Response - 2 Troy says he usually drinks about half a bottle of whisky on a Saturday night (shares a bottle with a friend) but he drank a whole bottle last weekend. He got into a fight about his girlfriend and then stormed off and got picked up by the police with a BAC of 0. 17 - he was still angry so was put in a cell overnight. This is his second offence. Does this change your response? What might Troy think about your response? Is he likely to change? Clinical Framework

Troy’s Response - 3 Troy says he doesn’t usually drink much maybe a 4 Troy’s Response - 3 Troy says he doesn’t usually drink much maybe a 4 pack of Jack Daniels once a week. He has been smoking cannabis on and off since he was 13 years old; for the last 18 months he’s smoked about 10 cones a day. Yesterday he had no money so didn’t use any cannabis. Ask: ‘Can you tell me how you felt yesterday after going without cannabis? ’ How could you explore if he wants to quit? What might Troy think about your response? What could you do? Clinical Framework

Troy’s Response - 4 Instead of asking for a sick certificate Troy wants a Troy’s Response - 4 Instead of asking for a sick certificate Troy wants a script for benzos. When you ask him to tell you more he says he uses heroin most days and needs the benzos because he hasn’t got any money to ‘score’ and wants to try and stop. You refuse and he gets aggressive and demanding - saying you are ‘forcing him to go out and use’. How could you respond? What can you do to minimise harm to Troy - what might he think about your response? Is he likely to change? Clinical Framework

Assisting Assessment and Response • In thinking about and responding to patients with drug Assisting Assessment and Response • In thinking about and responding to patients with drug use issues it can help to have a framework that assists in the formulation of a comprehensive assessment and relevant response • Significant factors likely to impact on successful management include: • a patient’s readiness to change • psychosocial / medical factors that facilitate or restrict change • physical & psychological harm from drug use Not everything needs to be done at once. Clinical Framework

Domains to Explore A Clinician’s View and Rationale • Pattern of drug use - Domains to Explore A Clinician’s View and Rationale • Pattern of drug use - to identify both patterns and problems associated with particular patterns of use, prevent complications and intervene early (? prevent progression) • Degree of dependence (if at all) - to identify need for and appropriate withdrawal management, medication etc and facilitate reliable mental state assessment • Dysfunctional cognition and behaviour - to identify likely complicating issues, limit prescribing harms, screen for underlying contributing conditions e. g. PTSD. Clinical Framework

For Each Domain Consider: • Key features (of regular use, intoxication or dependence) • For Each Domain Consider: • Key features (of regular use, intoxication or dependence) • Key clinical indicators • Useful features in history and presentation • Different identification and response potential • Key issues to ensure appropriate assessment in GP setting Please refer to Handout 1 Clinical Framework

A Clinical Framework 3 Domains Patterns & Problems to Explore I R D Treatment A Clinical Framework 3 Domains Patterns & Problems to Explore I R D Treatment Approach Dependence Associated Behaviours Patient Choices Continue +/- unchanged Modification Stop Substitution Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Clinical Framework

Using the Framework in Practice Troy 1 Patterns & Problems • drinks 6 cans Using the Framework in Practice Troy 1 Patterns & Problems • drinks 6 cans of Jack Daniels most Saturdays at parties • uses 1 or 2 ecstasy tabs. about once a month • last weekend, drank about double his usual ‘hung-over’ on Monday. • 2 nd time presented for sick certificate Dependence Associated Behaviours Low Risky High Risk I R D Patient Choices Continue +/- unchanged ? Modification ? Stop ? Substitution Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Clinical Framework

Using the Framework in Practice Troy 2 Patterns & Problems • drinks half a Using the Framework in Practice Troy 2 Patterns & Problems • drinks half a bottle of whisky - Sat. nights with his mate • whole bottle last w/end • fight with girlfriend, stormed off • picked up by police with BAC 0. 17 • spent night in cell - 2 nd offence Dependence Associated Behaviours Low Risky High Risk Patient Choices I R D Continue +/- unchanged ? Modification ? Stop ? Substitution Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Clinical Framework

Using the Framework in Practice Troy 3 Patterns & Problems Low Risky High Risk Using the Framework in Practice Troy 3 Patterns & Problems Low Risky High Risk • • drinks 4 pack Jack Daniels/once a week smoking cannabis on/off since age 13 last 18 months, smoked about 10 cones daily yesterday, no money so went without Dependence ? Psychological /physical withdrawal features Associated Behaviours 2 drugs Patient Choices I R D Continue +/- unchanged ? Modification ? Stop ? Substitution Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Clinical Framework

Using the Framework in Practice Troy 4 High Risk wants benzo script almost daily Using the Framework in Practice Troy 4 High Risk wants benzo script almost daily heroin no money, ? wants to stop heroin script refusal ---> aggression Dependence Patterns & Problems Low Risky • • ? Associated Behaviours Psychological /physical withdrawal features Addictive Behaviours Patient Choices I R D Continue +/- unchanged ? Modification ? Stop ? Substitution ? Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Clinical Framework

Opportunities for Intervention Presenting Complaint Action • related to AOD ? identify use level Opportunities for Intervention Presenting Complaint Action • related to AOD ? identify use level and patterns, encourage behaviour change if appropriate and reduce harms where relevant • related to AOD but patient unaware of link symptoms / problems i. e. personalise drug effects & offer help • clearly AOD related emphasise link and offer help • drug seeking engage in therapeutic relationship, offer controlled safer drug regime, harm reduction until cessation is possible Clinical Framework

Treatment Responses Please refer to Handout 2 Clinical Framework Treatment Responses Please refer to Handout 2 Clinical Framework

Patient …. Patterns & Problems Low Risky High Risk Degree of Dependence Psych ological Patient …. Patterns & Problems Low Risky High Risk Degree of Dependence Psych ological /physical withdrawal features Associated Behaviours Addictive Behaviours Patient Choices I R D Continue +/- unchanged Modification Stop Substitution Brief Intervention: Motivational Interviewing: Harm Minimisation: Relapse Prevention: Withdrawal: Referral Clinical Framework