- Email: [email protected]
Assessment of drug and alcohol misuse
HISTORY TAKING AND EXAMINATION
Most present as a non-tender, persistent swelling, though 20% present as intermittent swellings and 15% with infection, usually after an upper respiratory tract infection. On FNAC they are classically said to contain a straw-coloured acellular fluid, rich in cholesterol crystals. In a clinical setting, however, they are commonly found to contain a creamy or turbid fluid. Treatment is by excision.
Assessment of drug and alcohol misuse Francis Keaney
Parapharyngeal swellings Parapharyngeal lesions may expand either medially, displacing the tonsil towards the mid-line, or by lateral displacement of the retromandibular portion of the parotid gland, thus presenting as a diffuse swelling in the upper deep cervical area. The most common cause is lymph node enlargement in the parapharyngeal space, though they may also result from deep lobe parotid tumours, lipomas and neurogenous tumours (e.g. neurofibromas, paragangliomas).
Aspects of assessment Doctors and other health professionals are relatively poor at taking substance misuse histories in primary care, general hospital and mental health settings. A number of reasons have been cited for this failure: lack of time, reticence about broaching such a sensitive topic, a stereotypical view of substance users, lack of confidence and a perceived lack of training have all been proffered as explanations. Sometimes negative attitudes are the real cause. Failure to screen and assess individuals for substance use and/or comorbid disorders means that opportunities for interventions and treatment are missed.1 Clinical assessment lays the foundation for treatment. It should enable the patient to engage in treatment and can act as a treatment intervention in its own right. More than one session may be needed. Collateral interviews with family members can be helpful, as can careful review of previous case notes and GP records. Above all, it should be a positive experience. Assessment has been defined as a process designed to reach a thorough understanding of a person’s problems in the overall context of his or her life, with the object of developing a treatment plan that stands the best chance of being helpful. 2 In the wider context, increasing emphasis is now given to comprehensive assessment, encompassing the broad range of individuals’ health and social needs.
FURTHER READING Browse N L. An introduction to the symptoms and signs of surgical disease. London: Edward Arnold, 1997. Jones A S. Phillips D E, Hilgers F J M. Diseases of the head and neck, nose and throat. London: Arnold, 1998.
The purpose of assessment is to identify the needs of the individual in order to inform decisions about treatment, care and support. Assessment involves many interacting variables that contribute to the individual’s uniqueness and general level of functioning. Thus multiple measures of biological, psychological and social systems must be collected, integrated and interpreted. The distinction between clinical assessment and diagnosis should be highlighted. Although the two cannot be separated entirely, assessment should be considered a process of gathering information for the purpose of understanding, whereas diagnosis is a process of classification.
Practice points • Cervical lymph node enlargement is the most common cause of a swelling in the neck. • A thorough examination of the upper aerodigestive tract is an essential step in the assessment of a neck lump. • Fine needle aspiration of the neck lump should be the first-line interventional investigation – not excision biopsy. • It is possible to predict the site of a primary tumour based on the distribution of cervical metastases. • If in doubt, seek the advice of an otolaryngologist or head and neck surgeon.
FOUNDATION YEARS 1:2
Francis Keaney y is Consultant Addiction Psychiatrist at the The Maudsley Hospital, London, UK. His research interests include dual diagnosis, alcohol and sexual health and alcohol markers for drink drivers.
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© 2005 The Medicine Publishing Company Ltd
HISTORY TAKING AND EXAMINATION
cate whether it is appropriate to refer an individual elsewhere, such as funding a place in a rehabilitation unit. Specialist assessment may be appropriate when a patient has been referred on to a specialist agency (community drug or alcohol team, in-patient or rehabilitation unit) or has moved on from entrylevel assessment. This in-depth assessment covers in detail the nature and extent of drug use, physical and psychological health, personal and social skills, social and economic circumstances, previous treatment episodes and the attributes of the individual.
Aims of assessment The commonplace nature of substance disorders means that brief screening followed by brief advice is necessary as part of generic psychiatric assessment in order to: • identify people with problems • treat any emergency or acute problem • confirm the patient is drinking or taking drugs • assess the degree of dependence • identify any complications of alcohol or drug misuse • assess risk behaviour • identify other medical, social and mental health problems • give advice on harm minimization • determine the patient’s expectations of treatment and degree of motivation to change • assess the most appropriate level of expertise required for patient management • determine the need for substitute medication (Department of Health, 1999).
Elements of the assessment The assessment process can comprise various elements including clinical interview, detailed inventory of drug and/or alcohol use, physical examination, biochemical investigations and the administration of assessment questionnaires (Figure 1). Many patients will require treatment, care and support from a number of service providers either at the same time or serially. A major cause of frustration for the patient is the duplication and constant repetition that this entails. Acknowledgement that this can happen and a few reassuring words at the outset may help smooth the interview process. Clinicians should set aside enough time for an unhurried, uninterrupted assessment. It is always helpful to start the interview with some information about the amount of time available and when breaks can be taken.
Levels of assessment Three levels of assessment have been suggested. 3 Simple assessment (screening and referral assessment) on first contact with professionally qualified staff in health (e.g. walk-in clinic), housing and social work setting to ensure an appropriate referral is made. Screening is provided to detect the presence of substance use disorders and related problem areas. This first-level assessment could be described as the ‘gateway’ into a process of care. Data collected at this stage are likely to be relatively basic: probably sociodemographic information, including cursory information about drug use and its likely impact on the individual’s ability to access services. Simple assessment could allow access to low-level services, such as harm-reduction advice and information. Comprehensive assessmentt may be used in health and social care settings when the individual has made a direct approach or has been referred by another agency. This assessment could cover more detailed information on drug use and other factors such as housing, employment, health and benefits. It should allow some decisions about treatment care and support to be made, and indi-
Clinical interview Assessment has a large therapeutic component and the relationship established with the patient at the first interview can determine whether they return for a second appointment, engage in treatment or accept recommendations for change. Drug history The aim is to elicit as accurately as possible details of past and current drug-taking behaviour. It should cover the following areas. • Reason for presentation – why now? • Past and current drug use – age of starting drug misuse; what drugs? Route (e.g. oral, smoked, snorted, injected), amount, source of supply. Typical day and week.
Advantages and disadvantages of different assessment procedures4 Procedure Biochemical investigations
Questionnaires Clinical interview
Advantages Objective Quick and convenient If positive, useful to monitor subsequent progress Objective and standardized Inexpensive and convenient Flexible Potentially high specificity Potential to detect cases that lab tests or questionnaires would miss
Disadvantages Limited sensitivity and specificity Can be expensive Do not detect social/psychological problems Subject to honesty of respondent Limited sensitivity and specificity Subjective Dependent on clinical skill and time/trouble taken Poor sensitivity if client is embarrassed or covering up Can be time-consuming
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FOUNDATION YEARS 1:2
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© 2005 The Medicine Publishing Company Ltd
HISTORY TAKING AND EXAMINATION
• Evidence of physical or psychological dependence on the drug. • History of injecting and risk of HIV and hepatitis – needle sharing, with whom? Equipment supply and cleaning. Sexual practices – condom use, prostitution. • Past contact with treatment services – what, where, how effective? • Medical history – complications of drug use. HIV, hepatitis B and C status, if known. Last menstrual period. Operations, accidents, head injury. • Forensic history – past and present contact with criminal justice system. Cases pending? Violence? • Psychiatric history – admission/out-patient attendance. Any overdoses? Previous episodes of depression or psychosis? • Family history – parents and siblings. History of mental illness/substance misuse? • Personal history – pregnancy and birth, childhood. Education to what level? • Occupational history – jobs and length of employment/unemployment. • Psychosexual history – menstrual/sexual/marital history. Type/ length/quality of relationships. Pregnancies. • Social history – housing, finances, social supports. Activities of daily living. • Premorbid personality – hobbies and interests. Mood, character, attitudes; morals and standards. Current drug use – which drugs is the patient currently using? The clinician should go through a typical drug-using day: how often, which route? Ask about the circumstances of drug use (only in social circumstances – e.g. ecstasy at a club?); is there a regular pattern that prevents withdrawal symptoms? History of drug use – if the patient has used more than one drug in the past, it is usually easier to take a chronological history of each drug in turn rather than trying to assess them all at once.
• persisting with drinking in spite of clear evidence of overtly harmful consequences. Some alcohol-related problems Physical – gastritis, cirrhosis, oesophageal varices, seizures, head injury, etc. Neuropsychiatric – memory blackouts, delirium tremens, depression, suicide attempts, pathological jealousy, alcoholic hallucinosis, etc. Social – marital, financial, occupational and forensic problems. Alcohol history in the context of background history Family history – family attitudes to alcohol, drinking history of parents and extended family, family history of alcohol and other psychiatric problems. Occupational history – work and occupational problems connected to alcohol such as dismissal, absenteeism and frequent job changes. Sexual and marital history – alcohol-related sexual problems (e.g. impotence), history of childhood sexual abuse (particularly important in women with alcohol problems), relationship and marital problems related to drinking. Financial and housing history – rent arrears, evictions, homelessness, problems with neighbours. Forensic history – drink-driving convictions, drunk and disorderly and violent behaviour. Past medical and psychiatric history – alcohol-related physical and psychological problems and accidents. Depression, phobic anxiety, pathological jealousy, suicide attempts and drug misuse. Treatment history – GP, out- or in-patient psychiatric treatment, voluntary or statutory community alcohol teams, residential rehabilitation, self-help groups (e.g. Alcoholics Anonymous).
Assessing alcohol and drinking problems It is best to start the assessment with an open and non-specific question – such as ‘what do you perceive as the main problem?’ – rather than moving directly to questions about quantity and frequency of consumption.5 The alcohol history should be taken in the context of the patient’s background history. Also of importance is the evolution of their drinking, current alcohol consumption (ask about a typical recent heavy drinking day), the evolution of alcohol dependence, alcohol-related problems and treatment history. Drinking history – the clinician should enquire about age of: • first drink • regular weekend drinking • regular evening drinking • regular lunchtime drinking • early morning drinking. Consumption should be determined in units (1 unit = 8–10 g of alcohol = 1 glass of wine, ½ pint of ordinary strength beer/lager/ cider, or 1 measure of spirits). The clinician should note age of onset of withdrawal symptoms and other features of the alcohol dependence syndrome (ICD-10), such as: • compulsion to drink • difficulties in controlling alcohol consumption • tolerance • progressive neglect of alternative pleasures or interests
FOUNDATION YEARS 1:2
Screening questionnaires The most typical and cost-effective method of screening in the primary care or general medical setting is to use standardized questionnaires. These instruments facilitate the collection of information in a systematic way and outcomes can be measured, contrasted and compared, in order to assist the practitioner and patient in identifying the nature and extent of problems. There are many comprehensive assessment instruments, not all of which have evidence of validity and reliability, so it is recommended that as a minimum they allow assessment of the following domains: • drug use • alcohol use • psychological problems • physical problems • social problems • legal problems.6 Questionnaires can be used to help guide and structure dialogue. The use of self-report questionnaires can optimize response rates. However, it is also important to check the internal consistency of information gained, and interviews with family members, friends or other people in close contact with the individual are often invaluable. They will also be able to provide qualitative informa-
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© 2005 The Medicine Publishing Company Ltd
HISTORY TAKING AND EXAMINATION
tion about how the person’s drug use is affecting them and those around them.
with the patient, as complete a picture as possible of their needs and their state of readiness to change, in order to provide the most appropriate services likely to promote a positive outcome.
Factors to consider when choosing an assessment questionnaire Primary usee – does the tool match your requirements? Qualitative vs quantitative information. Target patient group – is the tool validated or appropriate for the patient group? Time framee – instruments vary in both the design and the time frame they capture. Type of substance used – some tools have limited relevance (e.g. to those who do not inject). Time taken to completee – a few minutes to several hours. The Alcohol Use Disorders Identification Test (AUDIT) was designed to increase the detection of hazardous and harmful drinking in generalist settings. Initially a 10-item questionnaire was used, but the shorter 5-item version has been shown to perform equally well (see Figure 2). The CAGE questionnaire (Figure 3) performs better than the AUDIT as a screening questionnaire for lifetime and current alcohol dependence. The Maudsley Addiction Profile (MAP) is a helpful tool for drug screening. Figure 4 shows a low-threshold drug screen modified from the MAP. An effective assessment process is at the core of effective service delivery and coordination. Assessment is the key to establishing,
Asking about quantity and frequency Alcohol – it is important to quantify the amount someone
CAGE questionnaire The CAGE questionnaire is a four-item test; it is useful for quickly picking up the more severe degrees of alcohol misuse 1 2 3 4
Have you ever felt you ought to Cut down your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about your drinking? Have you ever had a drink first thing in the morning as an ‘Eye-opener’?
Two or more positive replies identify problem drinkers; one is an indication for further enquiry about the person’s drinking
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Five-item AUDIT7 Have you consumed ANY alcohol within the last 12 months? (please tick)
YES
NO
If NO: do not continue If YES: please answer the following questions. Please circle the appropriate answer and then record the points score for that item in the right-hand column. At the end of the section, add up the scores in the right-hand column and complete the total score box to determine the outcome.
Points per item How often do you have a drink that contains alcohol?
4 4+ times weekly 10+ units
3 2–3 times weekly 7–9 units
Score 2 2–4 times monthly 5 or 6 units
1 Monthly or less 3 or 4 units
How many drinks containing alcohol do you have on a typical day when you are drinking? (code number of units1) How often during the last year have you found that you Daily or Weekly Monthly Less than were not able to stop drinking once you had started? almost daily monthly How often during the last year have you failed to do what Daily or Weekly Monthly Less than is expected of you because of your drinking? almost daily monthly Has a relative/friend/doctor or health worker been concerned about your drinking or suggested you cut down? Yes, during the last year Yes, but not in the last year
1 or 2 units Never Never No
TOTAL SCORE Negative Positive
A score of more than 5 suggests problematic use that requires further investigation. OUTCOME (please circle): 1
0 Never
1 unit = 1 glass of wine, 1 measure of spirits or ½ pint ordinary beer/lager/cider.
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HISTORY TAKING AND EXAMINATION
• hallucinogens • cannabinoids • inhalants • nicotine. With cannabis, for example, the patient should be asked whether they have ever used and then about details of current use, if applicable, such as the number of joints, the type of cannabis and the amount used weekly.
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Low-threshold drug screen
Please read to the patient: In the last 12 months, how often have you used the following illicit substances or prescribed medications? (where 8 = not used in the last 12 months, and 9 = used at least once in the last 12 months)
Substance
Physical examination As with other areas of psychiatric practice, physical examination is an essential part of assessment and ongoing monitoring. Clinicians should look for: • signs of drug use – needle marks (injection sites in arms, legs and groin), skin abscesses, infected sinuses, pupillary changes, nasal discharge or rash • signs of intoxication or withdrawal • comorbidity – viral hepatitis, bacterial endocarditis, HIV, tuberculosis, septicaemia, pneumonia, deep vein thrombosis, pulmonary emboli, abscesses and dental disease.
Use in last 12 months
Cannabis Hallucinogens (LSD, ecstasy, mushrooms) Ketamine Amphetamines (speed) Cocaine powder Crack cocaine Heroin Prescribed
Non-prescribed
Mental health assessment Psychiatric disorders can occur independently of substance use. However, some drugs can induce psychosis (amphetamines and cocaine, cannabis) or exacerbate existing psychiatric disorders. Examination should include: • general behaviour (e.g. restlessness, anxiety and irritability can be caused by intoxication with hallucinogens or stimulants, or by withdrawal from opioids) • mood (e.g. depression can be caused by withdrawal from stimulants, alcohol or sedative drugs); assess risk of self-harm (suicidal ideation, previous suicide attempts) • delusions and hallucinations • confusional states.
Opioids (DF118, Temgesic, morphine, diamorphine, methadone) Codeine Procyclidine Other medications (e.g. asthma, steroids). Please specify NAME AND DOSE:_____ _________________ Benzodiazepines (valium, temazepam, nitrazepam, mogadon)
Assessing motivation Is the substance user motivated to stop or change their pattern of drug use or to make other changes in their life? The practitioner may need to encourage realistic goals (short, intermediate and long term). Every effort should be made to encourage motivation. When there is resistance to change drug misuse itself, there is often motivation to make changes in other parts of life such as in personal relationships, accommodation and employment.
Score POSITIVE if the client reports having used at any time over the last year either: 1) An illicit drug or 2) A prescribed substitute (methadone/DF118) or 3) A prescribed drug that is not prescribed to them OUTCOME (please circle)
Negative
Positive
4
drinks on a daily and weekly basis in units. To do this the clinician should go through a typical drinking day on an hourly basis and write down the type of alcohol, strength (if known) and amount drunk, and convert this into units. Patients can keep a ‘drinks diary’ themselves so they can compare their intake with recommended drinking levels. Drugs – when taking a drug history the clinician should ask about ‘ever use’ and use in the last 28–30 days. It is helpful to have a reminder of the classes of drugs to ask about: • stimulants • opioids • hypnotics
FOUNDATION YEARS 1:2
REFERENCES 1 Barnaby B, Drummond C, McCloud A, Burns T, Omu N. Substance misuse in psychiatric inpatients: comparison of a screening questionnaire survey with case notes. BMJJ 2003; 327: 783–4.
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COMMUNICATION SKILLS
The psychological aspects of palliative care
2 World Health Organization, 2002. Online at: http://www.who. int/substance_abuse/topic_assessment.htm 3 Rome A, Morrison A, Duff L, Martin J, Russell P. Integrated care for drug users: principles and practice. Edinburgh: Scottish Executive Effective Interventions Unit, 2002. 4 Edwards G, Marshall E J, Cook C C H. The treatment of drinking problems: a guide for the helping professions, 4th edn. Cambridge: Cambridge University Press, 2003. 5 Goldberg D, Murray R. The Maudsley handbook of practical psychiatry, 4th edn. Oxford: Oxford University Press, 2002. 6 Department of Health. Models of care for substance misuse treatment. Summary report. London: Department of Health, 2002. 7 Piccinelli M, Tessari E, Bortoomasi M et al. Efficacy of the Alcohol Use Disorders Identification Test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study. BMJJ 1997; 314: 420–4. 8 Marsden J, Gossop M, Stewart D et al. The Maudsley Addiction Profile (MAP): a brief instrument for assessing treatment outcome. Addiction 1998; 93: 1857–68.
Karen Collis
Palliative care was defined by the World Health Organization in 1990 as ‘The active, total care of patients at a time when their disease is no longer responsive to curative treatment, and when control of pain or other symptoms and of psychological, social and spiritual problems is paramount.’ Palliative care complements existing healthcare and functions in partnership with the multidisciplinary team. It should not be considered as being merely concerned with decisions regarding whether to treat or not, but with the appropriateness of a treatment. Palliative care is concerned with all chronic diseases and many goals of palliative care are applicable in the initial stages of any illness. The principles of palliative care (Figure 1) are derived form the primary objective or promoting the physical and psychological well-being of the patient and his or her family. The facilitation of palliative care intervention incorporates three essential components: • psychosocial support • symptom control • teamwork and partnership. The environment in which palliative care is required is one of change and uncertainty.
FURTHER READING Chick J, Cantwell R, eds. Seminars in alcohol and drug misuse. London: Royal College of Psychiatrists, 1994. Department of Health. Drug misuse and Dependence – guidelines on clinical management. London: Stationery Office, 1999. Donovan D M, Marlatt G A, eds. Assessment of addictive behaviours. London: Hutchinson, 1988. National Institute on Alcohol Abuse and Alcoholism. Online at http://www.niaaa.nih.gov Substance Misuse. Online at http://www.substancemisuse. net/practitioners Drummond D C, Ghodse H. Use of investigations in the diagnosis and management of alcohol use disorders. Adv Psychiatr Treat 1999; 5: 366–75. Rome A. Integrated care for drug users: Digest of tools used in the assessment process and core data sets. Edinburgh: Scottish Executive Effective Interventions Unit, 2003.
Change Once an illness has been diagnosed as having no cure, an integral part of palliative care is helping the patient to adjust to a full awareness of the situation. Change is inevitable and unavoidable in both our personal and professional lives, and can be both planned and unplanned. Change alters the way we do things and the way in which we think about things. Change is not always a single process. It is brought about by a series of events that together produce change. This is due to the different ways in which individuals respond to events creating change. This reaction is unique to each individual, being influence by age, culture, religion and the psychological and spiritual core of the person.
Karen Collis is a Clinical Nurse Specialist in Palliative Care at the Royal Brompton and Harefield NHS Trust, UK.
FOUNDATION YEARS 1:2
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Most present as a non-tender, persistent swelling, though 20% present as intermittent swellings and 15% with infection, usually after an upper respiratory tract infection. On FNAC they are classically said to contain a straw-coloured acellular fluid, rich in cholesterol crystals. In a clinical setting, however, they are commonly found to contain a creamy or turbid fluid. Treatment is by excision.
Assessment of drug and alcohol misuse Francis Keaney
Parapharyngeal swellings Parapharyngeal lesions may expand either medially, displacing the tonsil towards the mid-line, or by lateral displacement of the retromandibular portion of the parotid gland, thus presenting as a diffuse swelling in the upper deep cervical area. The most common cause is lymph node enlargement in the parapharyngeal space, though they may also result from deep lobe parotid tumours, lipomas and neurogenous tumours (e.g. neurofibromas, paragangliomas).
Aspects of assessment Doctors and other health professionals are relatively poor at taking substance misuse histories in primary care, general hospital and mental health settings. A number of reasons have been cited for this failure: lack of time, reticence about broaching such a sensitive topic, a stereotypical view of substance users, lack of confidence and a perceived lack of training have all been proffered as explanations. Sometimes negative attitudes are the real cause. Failure to screen and assess individuals for substance use and/or comorbid disorders means that opportunities for interventions and treatment are missed.1 Clinical assessment lays the foundation for treatment. It should enable the patient to engage in treatment and can act as a treatment intervention in its own right. More than one session may be needed. Collateral interviews with family members can be helpful, as can careful review of previous case notes and GP records. Above all, it should be a positive experience. Assessment has been defined as a process designed to reach a thorough understanding of a person’s problems in the overall context of his or her life, with the object of developing a treatment plan that stands the best chance of being helpful. 2 In the wider context, increasing emphasis is now given to comprehensive assessment, encompassing the broad range of individuals’ health and social needs.
FURTHER READING Browse N L. An introduction to the symptoms and signs of surgical disease. London: Edward Arnold, 1997. Jones A S. Phillips D E, Hilgers F J M. Diseases of the head and neck, nose and throat. London: Arnold, 1998.
The purpose of assessment is to identify the needs of the individual in order to inform decisions about treatment, care and support. Assessment involves many interacting variables that contribute to the individual’s uniqueness and general level of functioning. Thus multiple measures of biological, psychological and social systems must be collected, integrated and interpreted. The distinction between clinical assessment and diagnosis should be highlighted. Although the two cannot be separated entirely, assessment should be considered a process of gathering information for the purpose of understanding, whereas diagnosis is a process of classification.
Practice points • Cervical lymph node enlargement is the most common cause of a swelling in the neck. • A thorough examination of the upper aerodigestive tract is an essential step in the assessment of a neck lump. • Fine needle aspiration of the neck lump should be the first-line interventional investigation – not excision biopsy. • It is possible to predict the site of a primary tumour based on the distribution of cervical metastases. • If in doubt, seek the advice of an otolaryngologist or head and neck surgeon.
FOUNDATION YEARS 1:2
Francis Keaney y is Consultant Addiction Psychiatrist at the The Maudsley Hospital, London, UK. His research interests include dual diagnosis, alcohol and sexual health and alcohol markers for drink drivers.
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© 2005 The Medicine Publishing Company Ltd
HISTORY TAKING AND EXAMINATION
cate whether it is appropriate to refer an individual elsewhere, such as funding a place in a rehabilitation unit. Specialist assessment may be appropriate when a patient has been referred on to a specialist agency (community drug or alcohol team, in-patient or rehabilitation unit) or has moved on from entrylevel assessment. This in-depth assessment covers in detail the nature and extent of drug use, physical and psychological health, personal and social skills, social and economic circumstances, previous treatment episodes and the attributes of the individual.
Aims of assessment The commonplace nature of substance disorders means that brief screening followed by brief advice is necessary as part of generic psychiatric assessment in order to: • identify people with problems • treat any emergency or acute problem • confirm the patient is drinking or taking drugs • assess the degree of dependence • identify any complications of alcohol or drug misuse • assess risk behaviour • identify other medical, social and mental health problems • give advice on harm minimization • determine the patient’s expectations of treatment and degree of motivation to change • assess the most appropriate level of expertise required for patient management • determine the need for substitute medication (Department of Health, 1999).
Elements of the assessment The assessment process can comprise various elements including clinical interview, detailed inventory of drug and/or alcohol use, physical examination, biochemical investigations and the administration of assessment questionnaires (Figure 1). Many patients will require treatment, care and support from a number of service providers either at the same time or serially. A major cause of frustration for the patient is the duplication and constant repetition that this entails. Acknowledgement that this can happen and a few reassuring words at the outset may help smooth the interview process. Clinicians should set aside enough time for an unhurried, uninterrupted assessment. It is always helpful to start the interview with some information about the amount of time available and when breaks can be taken.
Levels of assessment Three levels of assessment have been suggested. 3 Simple assessment (screening and referral assessment) on first contact with professionally qualified staff in health (e.g. walk-in clinic), housing and social work setting to ensure an appropriate referral is made. Screening is provided to detect the presence of substance use disorders and related problem areas. This first-level assessment could be described as the ‘gateway’ into a process of care. Data collected at this stage are likely to be relatively basic: probably sociodemographic information, including cursory information about drug use and its likely impact on the individual’s ability to access services. Simple assessment could allow access to low-level services, such as harm-reduction advice and information. Comprehensive assessmentt may be used in health and social care settings when the individual has made a direct approach or has been referred by another agency. This assessment could cover more detailed information on drug use and other factors such as housing, employment, health and benefits. It should allow some decisions about treatment care and support to be made, and indi-
Clinical interview Assessment has a large therapeutic component and the relationship established with the patient at the first interview can determine whether they return for a second appointment, engage in treatment or accept recommendations for change. Drug history The aim is to elicit as accurately as possible details of past and current drug-taking behaviour. It should cover the following areas. • Reason for presentation – why now? • Past and current drug use – age of starting drug misuse; what drugs? Route (e.g. oral, smoked, snorted, injected), amount, source of supply. Typical day and week.
Advantages and disadvantages of different assessment procedures4 Procedure Biochemical investigations
Questionnaires Clinical interview
Advantages Objective Quick and convenient If positive, useful to monitor subsequent progress Objective and standardized Inexpensive and convenient Flexible Potentially high specificity Potential to detect cases that lab tests or questionnaires would miss
Disadvantages Limited sensitivity and specificity Can be expensive Do not detect social/psychological problems Subject to honesty of respondent Limited sensitivity and specificity Subjective Dependent on clinical skill and time/trouble taken Poor sensitivity if client is embarrassed or covering up Can be time-consuming
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HISTORY TAKING AND EXAMINATION
• Evidence of physical or psychological dependence on the drug. • History of injecting and risk of HIV and hepatitis – needle sharing, with whom? Equipment supply and cleaning. Sexual practices – condom use, prostitution. • Past contact with treatment services – what, where, how effective? • Medical history – complications of drug use. HIV, hepatitis B and C status, if known. Last menstrual period. Operations, accidents, head injury. • Forensic history – past and present contact with criminal justice system. Cases pending? Violence? • Psychiatric history – admission/out-patient attendance. Any overdoses? Previous episodes of depression or psychosis? • Family history – parents and siblings. History of mental illness/substance misuse? • Personal history – pregnancy and birth, childhood. Education to what level? • Occupational history – jobs and length of employment/unemployment. • Psychosexual history – menstrual/sexual/marital history. Type/ length/quality of relationships. Pregnancies. • Social history – housing, finances, social supports. Activities of daily living. • Premorbid personality – hobbies and interests. Mood, character, attitudes; morals and standards. Current drug use – which drugs is the patient currently using? The clinician should go through a typical drug-using day: how often, which route? Ask about the circumstances of drug use (only in social circumstances – e.g. ecstasy at a club?); is there a regular pattern that prevents withdrawal symptoms? History of drug use – if the patient has used more than one drug in the past, it is usually easier to take a chronological history of each drug in turn rather than trying to assess them all at once.
• persisting with drinking in spite of clear evidence of overtly harmful consequences. Some alcohol-related problems Physical – gastritis, cirrhosis, oesophageal varices, seizures, head injury, etc. Neuropsychiatric – memory blackouts, delirium tremens, depression, suicide attempts, pathological jealousy, alcoholic hallucinosis, etc. Social – marital, financial, occupational and forensic problems. Alcohol history in the context of background history Family history – family attitudes to alcohol, drinking history of parents and extended family, family history of alcohol and other psychiatric problems. Occupational history – work and occupational problems connected to alcohol such as dismissal, absenteeism and frequent job changes. Sexual and marital history – alcohol-related sexual problems (e.g. impotence), history of childhood sexual abuse (particularly important in women with alcohol problems), relationship and marital problems related to drinking. Financial and housing history – rent arrears, evictions, homelessness, problems with neighbours. Forensic history – drink-driving convictions, drunk and disorderly and violent behaviour. Past medical and psychiatric history – alcohol-related physical and psychological problems and accidents. Depression, phobic anxiety, pathological jealousy, suicide attempts and drug misuse. Treatment history – GP, out- or in-patient psychiatric treatment, voluntary or statutory community alcohol teams, residential rehabilitation, self-help groups (e.g. Alcoholics Anonymous).
Assessing alcohol and drinking problems It is best to start the assessment with an open and non-specific question – such as ‘what do you perceive as the main problem?’ – rather than moving directly to questions about quantity and frequency of consumption.5 The alcohol history should be taken in the context of the patient’s background history. Also of importance is the evolution of their drinking, current alcohol consumption (ask about a typical recent heavy drinking day), the evolution of alcohol dependence, alcohol-related problems and treatment history. Drinking history – the clinician should enquire about age of: • first drink • regular weekend drinking • regular evening drinking • regular lunchtime drinking • early morning drinking. Consumption should be determined in units (1 unit = 8–10 g of alcohol = 1 glass of wine, ½ pint of ordinary strength beer/lager/ cider, or 1 measure of spirits). The clinician should note age of onset of withdrawal symptoms and other features of the alcohol dependence syndrome (ICD-10), such as: • compulsion to drink • difficulties in controlling alcohol consumption • tolerance • progressive neglect of alternative pleasures or interests
FOUNDATION YEARS 1:2
Screening questionnaires The most typical and cost-effective method of screening in the primary care or general medical setting is to use standardized questionnaires. These instruments facilitate the collection of information in a systematic way and outcomes can be measured, contrasted and compared, in order to assist the practitioner and patient in identifying the nature and extent of problems. There are many comprehensive assessment instruments, not all of which have evidence of validity and reliability, so it is recommended that as a minimum they allow assessment of the following domains: • drug use • alcohol use • psychological problems • physical problems • social problems • legal problems.6 Questionnaires can be used to help guide and structure dialogue. The use of self-report questionnaires can optimize response rates. However, it is also important to check the internal consistency of information gained, and interviews with family members, friends or other people in close contact with the individual are often invaluable. They will also be able to provide qualitative informa-
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© 2005 The Medicine Publishing Company Ltd
HISTORY TAKING AND EXAMINATION
tion about how the person’s drug use is affecting them and those around them.
with the patient, as complete a picture as possible of their needs and their state of readiness to change, in order to provide the most appropriate services likely to promote a positive outcome.
Factors to consider when choosing an assessment questionnaire Primary usee – does the tool match your requirements? Qualitative vs quantitative information. Target patient group – is the tool validated or appropriate for the patient group? Time framee – instruments vary in both the design and the time frame they capture. Type of substance used – some tools have limited relevance (e.g. to those who do not inject). Time taken to completee – a few minutes to several hours. The Alcohol Use Disorders Identification Test (AUDIT) was designed to increase the detection of hazardous and harmful drinking in generalist settings. Initially a 10-item questionnaire was used, but the shorter 5-item version has been shown to perform equally well (see Figure 2). The CAGE questionnaire (Figure 3) performs better than the AUDIT as a screening questionnaire for lifetime and current alcohol dependence. The Maudsley Addiction Profile (MAP) is a helpful tool for drug screening. Figure 4 shows a low-threshold drug screen modified from the MAP. An effective assessment process is at the core of effective service delivery and coordination. Assessment is the key to establishing,
Asking about quantity and frequency Alcohol – it is important to quantify the amount someone
CAGE questionnaire The CAGE questionnaire is a four-item test; it is useful for quickly picking up the more severe degrees of alcohol misuse 1 2 3 4
Have you ever felt you ought to Cut down your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about your drinking? Have you ever had a drink first thing in the morning as an ‘Eye-opener’?
Two or more positive replies identify problem drinkers; one is an indication for further enquiry about the person’s drinking
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Five-item AUDIT7 Have you consumed ANY alcohol within the last 12 months? (please tick)
YES
NO
If NO: do not continue If YES: please answer the following questions. Please circle the appropriate answer and then record the points score for that item in the right-hand column. At the end of the section, add up the scores in the right-hand column and complete the total score box to determine the outcome.
Points per item How often do you have a drink that contains alcohol?
4 4+ times weekly 10+ units
3 2–3 times weekly 7–9 units
Score 2 2–4 times monthly 5 or 6 units
1 Monthly or less 3 or 4 units
How many drinks containing alcohol do you have on a typical day when you are drinking? (code number of units1) How often during the last year have you found that you Daily or Weekly Monthly Less than were not able to stop drinking once you had started? almost daily monthly How often during the last year have you failed to do what Daily or Weekly Monthly Less than is expected of you because of your drinking? almost daily monthly Has a relative/friend/doctor or health worker been concerned about your drinking or suggested you cut down? Yes, during the last year Yes, but not in the last year
1 or 2 units Never Never No
TOTAL SCORE Negative Positive
A score of more than 5 suggests problematic use that requires further investigation. OUTCOME (please circle): 1
0 Never
1 unit = 1 glass of wine, 1 measure of spirits or ½ pint ordinary beer/lager/cider.
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HISTORY TAKING AND EXAMINATION
• hallucinogens • cannabinoids • inhalants • nicotine. With cannabis, for example, the patient should be asked whether they have ever used and then about details of current use, if applicable, such as the number of joints, the type of cannabis and the amount used weekly.
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Low-threshold drug screen
Please read to the patient: In the last 12 months, how often have you used the following illicit substances or prescribed medications? (where 8 = not used in the last 12 months, and 9 = used at least once in the last 12 months)
Substance
Physical examination As with other areas of psychiatric practice, physical examination is an essential part of assessment and ongoing monitoring. Clinicians should look for: • signs of drug use – needle marks (injection sites in arms, legs and groin), skin abscesses, infected sinuses, pupillary changes, nasal discharge or rash • signs of intoxication or withdrawal • comorbidity – viral hepatitis, bacterial endocarditis, HIV, tuberculosis, septicaemia, pneumonia, deep vein thrombosis, pulmonary emboli, abscesses and dental disease.
Use in last 12 months
Cannabis Hallucinogens (LSD, ecstasy, mushrooms) Ketamine Amphetamines (speed) Cocaine powder Crack cocaine Heroin Prescribed
Non-prescribed
Mental health assessment Psychiatric disorders can occur independently of substance use. However, some drugs can induce psychosis (amphetamines and cocaine, cannabis) or exacerbate existing psychiatric disorders. Examination should include: • general behaviour (e.g. restlessness, anxiety and irritability can be caused by intoxication with hallucinogens or stimulants, or by withdrawal from opioids) • mood (e.g. depression can be caused by withdrawal from stimulants, alcohol or sedative drugs); assess risk of self-harm (suicidal ideation, previous suicide attempts) • delusions and hallucinations • confusional states.
Opioids (DF118, Temgesic, morphine, diamorphine, methadone) Codeine Procyclidine Other medications (e.g. asthma, steroids). Please specify NAME AND DOSE:_____ _________________ Benzodiazepines (valium, temazepam, nitrazepam, mogadon)
Assessing motivation Is the substance user motivated to stop or change their pattern of drug use or to make other changes in their life? The practitioner may need to encourage realistic goals (short, intermediate and long term). Every effort should be made to encourage motivation. When there is resistance to change drug misuse itself, there is often motivation to make changes in other parts of life such as in personal relationships, accommodation and employment.
Score POSITIVE if the client reports having used at any time over the last year either: 1) An illicit drug or 2) A prescribed substitute (methadone/DF118) or 3) A prescribed drug that is not prescribed to them OUTCOME (please circle)
Negative
Positive
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drinks on a daily and weekly basis in units. To do this the clinician should go through a typical drinking day on an hourly basis and write down the type of alcohol, strength (if known) and amount drunk, and convert this into units. Patients can keep a ‘drinks diary’ themselves so they can compare their intake with recommended drinking levels. Drugs – when taking a drug history the clinician should ask about ‘ever use’ and use in the last 28–30 days. It is helpful to have a reminder of the classes of drugs to ask about: • stimulants • opioids • hypnotics
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REFERENCES 1 Barnaby B, Drummond C, McCloud A, Burns T, Omu N. Substance misuse in psychiatric inpatients: comparison of a screening questionnaire survey with case notes. BMJJ 2003; 327: 783–4.
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COMMUNICATION SKILLS
The psychological aspects of palliative care
2 World Health Organization, 2002. Online at: http://www.who. int/substance_abuse/topic_assessment.htm 3 Rome A, Morrison A, Duff L, Martin J, Russell P. Integrated care for drug users: principles and practice. Edinburgh: Scottish Executive Effective Interventions Unit, 2002. 4 Edwards G, Marshall E J, Cook C C H. The treatment of drinking problems: a guide for the helping professions, 4th edn. Cambridge: Cambridge University Press, 2003. 5 Goldberg D, Murray R. The Maudsley handbook of practical psychiatry, 4th edn. Oxford: Oxford University Press, 2002. 6 Department of Health. Models of care for substance misuse treatment. Summary report. London: Department of Health, 2002. 7 Piccinelli M, Tessari E, Bortoomasi M et al. Efficacy of the Alcohol Use Disorders Identification Test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study. BMJJ 1997; 314: 420–4. 8 Marsden J, Gossop M, Stewart D et al. The Maudsley Addiction Profile (MAP): a brief instrument for assessing treatment outcome. Addiction 1998; 93: 1857–68.
Karen Collis
Palliative care was defined by the World Health Organization in 1990 as ‘The active, total care of patients at a time when their disease is no longer responsive to curative treatment, and when control of pain or other symptoms and of psychological, social and spiritual problems is paramount.’ Palliative care complements existing healthcare and functions in partnership with the multidisciplinary team. It should not be considered as being merely concerned with decisions regarding whether to treat or not, but with the appropriateness of a treatment. Palliative care is concerned with all chronic diseases and many goals of palliative care are applicable in the initial stages of any illness. The principles of palliative care (Figure 1) are derived form the primary objective or promoting the physical and psychological well-being of the patient and his or her family. The facilitation of palliative care intervention incorporates three essential components: • psychosocial support • symptom control • teamwork and partnership. The environment in which palliative care is required is one of change and uncertainty.
FURTHER READING Chick J, Cantwell R, eds. Seminars in alcohol and drug misuse. London: Royal College of Psychiatrists, 1994. Department of Health. Drug misuse and Dependence – guidelines on clinical management. London: Stationery Office, 1999. Donovan D M, Marlatt G A, eds. Assessment of addictive behaviours. London: Hutchinson, 1988. National Institute on Alcohol Abuse and Alcoholism. Online at http://www.niaaa.nih.gov Substance Misuse. Online at http://www.substancemisuse. net/practitioners Drummond D C, Ghodse H. Use of investigations in the diagnosis and management of alcohol use disorders. Adv Psychiatr Treat 1999; 5: 366–75. Rome A. Integrated care for drug users: Digest of tools used in the assessment process and core data sets. Edinburgh: Scottish Executive Effective Interventions Unit, 2003.
Change Once an illness has been diagnosed as having no cure, an integral part of palliative care is helping the patient to adjust to a full awareness of the situation. Change is inevitable and unavoidable in both our personal and professional lives, and can be both planned and unplanned. Change alters the way we do things and the way in which we think about things. Change is not always a single process. It is brought about by a series of events that together produce change. This is due to the different ways in which individuals respond to events creating change. This reaction is unique to each individual, being influence by age, culture, religion and the psychological and spiritual core of the person.
Karen Collis is a Clinical Nurse Specialist in Palliative Care at the Royal Brompton and Harefield NHS Trust, UK.
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