Prepared by J. Mabbutt & C. Maynard NaMO September 2008 4: Drug and Alcohol use

Prepared by J. Mabbutt & C. MaynardNaMO

September 2008

4: Drug and Alcohol use

1. By the end of the session nurses & midwives will have an increase in their knowledge & skills to enable them to take a basic drug & alcohol use history & also to be aware of the broad issues regarding a thorough assessment

2. During the session nurses & midwives will participate in teaching activities to improve their ability to complete a basic drug and alcohol use history & increase their knowledge regarding a thorough assessment

4: Drug and Alcohol use assessment: Objectives

Nurses & midwives are well placed to assess, manage and intervene with someone’s drug & alcohol use

It is essential that nurses and midwives are well-equipped to identify presentations that require admission, treatment, referral or further investigation

Refer to NSW Health Policy, 2007 – “Nursing and Midwifery Management of Drug and Alcohol Issues in the Delivery of Health Care” for further information

4: Drug and Alcohol use assessment (1)

A drug & alcohol use assessment is important in order to:

Establish a correct diagnosis

Predict the effects of intoxication, assess its life-threatening potential, & plan appropriate intervention

Assess the possibility of drug interaction between the drug taken by the patient and drug(s) administered by the nurse, or between those already taken


Predict the possibility of withdrawal

Assess risk behaviours, including self harm

Ensure duty of care

Gain an understanding of the patient as a whole person, not merely in terms of their symptoms

Select appropriate therapeutic interventions


Some diagnoses may be confused with alcohol or drug intoxication or withdrawal

This can lead to significant medical problems being missed if the nurse or midwife does not look for causes beyond alcohol or drugs

Such problems include infection, hypoxia, hypoglycaemia and other metabolic imbalances, head injury, CVA, liver disease, drug overdose and psychosis


A systematic drug & alcohol use assessment of all patients, quantified & documented, including a thorough examination of:

– indicators of risk

– past medical history

– psychosocial issues

– physical signs & symptoms

– mental health status & pathology results

No single sign, symptom or pathology test is conclusive evidence of an alcohol or drug-related issue

4: General principles of Drug & Alcohol use assessment

The following key elements must be clarified with each patient as part of an assessment:

Type of drug (See Appendix 6 for street names)

Route of administration

Frequency of use

Dose & duration of use

Time & amount of the last dose, e.g. grams of alcohol or number of standard drinks, mls and mgs of methadone, grams of cannabis, etc

4: Key elements of assessment (1)

NOTE: It is important to ask the person if they are using more than one drug at a time, as polydrug use can significantly increase the risk involved

4: Key elements of assessment (2)

A person’s drug & alcohol use must be quantified, & include both prescribed & non-prescribed drugs

Determine whether the level of use may cause harm, and whether withdrawal or progression to overdose is imminent

For some substances such as alcohol, there is an agreed low risk level of consumption

For tobacco there is no safe level of consumption

4: Quantifying substance use (1)

Illicit drugs are difficult to quantify because the same drug can differ vastly from dose to dose in terms of purity & actual ingredients.

Nevertheless, for illicit drugs, document e.g. the number of injections, bongs, or the dollar cost or amount used (e.g. grams)

Many medications should only be taken if they are on prescription & in the way prescribed

4: Quantifying substance use (2)

Explain the patient’s right to privacy & any limits to confidentiality, e.g. if there are child protection issues

Patients need to be informed that the purpose of taking a drug & alcohol history is to obtain information that is relevant to their health / not a forensic investigation.

Information in most cases, can only be provided to third parties with written permission

Exceptions, for example, if the person is homicidal or suicidal; if there are current child protection issues or if a subpoena has been issued for the patient’s notes

4: Confidentiality

Smell of alcohol

Signs of alcohol use (see alcohol withdrawal presentation)

Puncture marks

Cellulitis/phlebitis

Skin abscesses

erosion or irritation around nostrils/septum

Irritation or rash around nose and mouth

4: Signs of drug & alcohol use administration: Some examples

Sweating

Tremor

Agitation

Disturbance of coordination, gait

Gooseflesh

Dilated pupils

Leg, stomach cramps

4: Signs of withdrawalSome examples

Excessive weight loss, signs of numerous old injuries, e.g. bruising

General physical health problems such as septicaemia, HIV, hepatitis B/C, jaundice

Mental health illness, treatment, involuntary admissions

Psychological distress/needing to do sex work/victim of rape/violence

Crime, jail, stealing from family & friends, selling possessions

Loss of relationships, employment, housing, savings etc

4: Consequences of use

Appearance & behaviour

Speech

Mood

Affect

Thought form; Thought content

Perception

Insight & Judgment

4: Mental Status Examination (1)

All health staff need to complete a preliminary screening for suicide risk as part of any assessment

Refer to NSW Health Department Policy PD2005_121 ‘Management of patients with possible suicidal behaviour.’ (there is also a CD-ROM resource for Mental Health and Non Mental Health Workers)

Refer also to NSW Mental Health Outcomes & Assessment Training Project (MH-OAT) developed to improve assessment skills for mental health staff

4: Mental Status Examination (2)

Besides the information that has been presented so far that needs to be collected on admission, there is some other important information to assess

The next slides cover three of a number important issues that should be part of an assessment

Child Protection & Domestic Violence screening are mandatory

HIV, Hepatitis B & C screening should also be part of any assessment, especially that hepatitis B is vaccine preventable and the high rate of Hepatitis C in injecting drug users

HIV, Hepatitis B & C Screening, Child Protection & Domestic Violence Issues

Hepatitis C is a major public health concern in Australia

Offer all patients screening for HIV, hepatitis B & C & advise on the availability of hepatitis B vaccination

Pre-test and post-test counselling must be provided as outlined in: NSW Health Policy Directive PD2005_048: Counselling associated with HIV antibody testing – guidelines.

For further information, see ‘Nurses & Hepatitis C’ – Australasian Society for HIV Medicine (ASHM) http://www.ashm.org.au/uploads/File/nurses-supp.pdf

4.8 HIV, Hepatitis B & C Screening

Health care workers have a duty under the NSW Children and Young Persons (Care and Protection) Act 1998 to notify the Department of Community Services whenever they suspect that a child or young person may be at risk of harm through abuse or neglect

It is important to note that drug & alcohol issue by a parent does not automatically equate to a child or young person being at risk

For further information, refer to: NSW Health Policy Directive PD2005_299. Protecting children and young people

NSW Health Frontline Procedures for the protection of children and young people. 2000

4.9 Child Protection Issues (1)

Pregnant opioid-dependent women should always be referred to Drug Use in Pregnancy Services

For further information, refer to the National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. (March 2006) http://www.health.nsw.gov.au/pubs/2006/ncg_druguse.html

NSW Health Neonatal Abstinence Syndrome (NAS) Guidelines, 2005 focus on care of opioid dependant women and care of the newborn from a child protection perspective

http://www.health.nsw.gov.au/policies/pd/2005/PD2005_494.html

4.9 Child Protection Issues (2)

Amongst those with drug & alcohol issues are significant numbers of both victims and perpetrators of domestic violence. Responding to this group presents particular challenges for nurses

For further information about the management of domestic violence and assessment of risk, refer to:

NSW Health Policy for Identifying and Responding to Domestic Violence, 2003

NSW Health Policy Directive PD2006_084. Identifying and responding to domestic violence

4: Domestic violence issues

Here are some points to remember when taking a history:

Normalise the assessment by telling the patient that you ask these questions to all patients

Try to make the environment as quiet and private as possible

Be mindful of the patient’s level of physical & emotional comfort

Note inconsistencies in what the patient tells you

4: Hints on taking a drug & alcohol history (1)

If a question angers the patient, leave it until later when you can rephrase the question

A history of the person’s drug and alcohol use can also be elicited from their spouse, friends or family, with the patients consent

Examine hospital medical records and speak to other health workers to gain supporting information for your history


When discussing drug & alcohol issues try to remain as non-threatening and non-judgmental as possible

The following techniques may help, but be mindful that they may not be suitable for every patient. Use discretion and professional judgment as to which may be useful

Introduce drinking/drug use as a normal, everyday experience, e.g. “What do you like to drink each day?

Ask about frequency of use e.g. “how often would you have a drink/use heroin/cannabis?” or ask “what is a typical day of drug use?”


Use open-ended questions, e.g. “How has your drinking/drug use changed over time?”

Try reflective listening, e.g. “Sounds like your drinking has been causing you problems lately”

Do not be distracted away from important points

Do not allow personal attitudes to affect the assessment

Be affirmative, e.g. “It takes a lot of courage to open up and talk about your drug use”


Be sensitive to the patient’s cultural background & language

Suggest high levels of drug and alcohol use, e.g. “How much would you normally drink in a session? Twenty schooners?”

However, when talking with adolescents, be careful that they do not perceive the overestimated amount as an expected figure, thereby encouraging them to exaggerate it further


Summarise, e.g. “On the one hand you like drinking because it helps you to relax but on the other hand you’re concerned about the effect it will have on the kids.”

Do not assume that the patient perceives their drug & alcohol use as a problem

If you don’t understand the jargon, ask the patient to explain

See a following slide for street names of drugs


Even ‘experts’ in the drug & alcohol field, may not know a street drug name

So, don’t be afraid to ask about the name, what another name is used for the drug, how it effects the person

By asking these questions you should be able to have a good idea what type of drug it is, by not asking you are not completing an assessment!

Surprisingly, drug uses will volunteer a lot of information about drugs to people who come across as interested, wanting to help & not judgmental – so ask!

4: Quantifying substance use Don’t be afraid to ask

Approved name of drug Street name Price in NSW, 2004-5 *

Alcohol Grog, piss, booze, sauce

Amphetamines Speed, goey, whiz, uppers, oxblood, point, crystal, crystal meth, ice, shabu

1 weight gram $90–$500

Benzodiazepines benzos, rowies, moggies, downers, sleepers, tummies, series, pills

Cannabis marijuana, grass, pot, shit, ganja, mull, hash, durry, green, dope, cone

Leaf- Ounce (28 g) $150Head- Ounce (28 g) $200 Hydroponic- (28 g) $250 Hash/resin- Deal (1g ) $50

Cocaine Snow, coke 1 gram $150–$300

Ecstasy E, eccies, XTC, fantasy, GBH, liquid ecstasy, good speed

1 tablet/capsule $30–$70

Heroin/ opioids Hammer, H, shit, smack, horse, harry, white, skag, junk

1 taste/cap (0.1–0.3 g) $50 Full gram $200–$500

* Adapted from the Illicit Drug Data Report. 2004–05 Australian Crime Commission

4: Appendix 6: Street names of drugs


Approved name of drug Street name Price in NSW, 2004-5 *

Ketamine Special K Varied across States: ACT - $65 S.A. - $200

Lysergic acid diethylamide (LSD)

Acid, blotter, trips, wangers, tabs, dots $10 to $25 per tab

Methylene Dioxyamphetamine (MDA)

Adam 1 tablet/capsule $30–$70

Methylene Dioxymethamphetamine (MDMA)

Ecstasy, Utopia, E, XTC 1 tablet/capsule $30–$70

Phencyclidine (PCP) Angel dust

PMA Dr Death

Psilocybin Magic mushrooms, gold tops

Solvents glue, tol, toluene, bute, nitrus, amyls, petrol, super, aerosol paint-chroming

4: Appendix 6: Street names of drugs


1. Handout cards with scenarios to participants (distribute) all cards (or use projector)

2. Lay the risk plates (4) across the floor

3. One participant reads out their card (or takes it in turn via the projector), then places it (or indicates which of the risk plates it relates to) on a risk plates. They are asked to explain why on that plate. They may fill in the gaps in the scenario to justify their decision. The group may assist.

4. A second participant continues this process until all scenarios are completed the time allocated is over.

RPA Education Unit CSAHS – Powell, Keen & Brown 1994

4: Assessment – Activity 3: Low risk – high risk Admission game

1. One nurse, patient and observer

2. The setting is on the ward 1 hour after admission

3. The patient is given a role play card which is not shown to the nurse, but the patient tells the nurse the reason for the admission. The nurse asks the patient about their substance use history. If this is a local substance use assessment tool is it recorded on that or just on a piece of paper in a systematic way, one at a time.

4. The observers only record information for constructive feedback.

RPA Education Unit CSAHS – Powell, Keen & Brown 1994

4: Assessment – Activity 4:Admission role play activity (1)

5. Patients are not to overact and should make it fairly easy for the nurse!

6. At the end of the time period the nurse and patient swap chairs. The nurse debriefs about what the experience was like, then is followed by the patient and the observer.

7. The nurse can now look at the role play card to see how accurate they were in the assessment

8. This is not a test, just practice, so relax!

Developed by Mabbutt 2003

4: Assessment Admission role play activity 4 (2)

The following key elements must be clarified with each patient as part of an assessment. Use these questions in the role play:

Type of drug (See Appendix 6 for street names)

Route of administration

Frequency of use

Dose & duration of use

Time & amount of the last dose, e.g. grams of alcohol or number of standard drinks, mls & mgs of methadone, grams of cannabis, etc

4: Assessment Admission role play activity 4 (3)

Show either of the videos below from the CIWAR-Ar CD- ROM and discuss

E3 Early detection of people at risk (alcohol) (9.04 min)

E4 Quantifying an alcohol history & Brief intervention using the AUDIT & Drinkless Resource (6.18 min)

See Opportunistic Intervention presentation No 5 for more details on the use of the AUDIT and Intervention re alcohol use

4: AssessmentQuantifying an alcohol history

Documents

Prepared by J. Mabbutt & C. Maynard NaMO September 2008 4: Drug and Alcohol use