You are a GP in a thriving regional centre. Sam, a 58-year-old store person and forklift driver, presents requesting prescribed cannabis. Sam started using cannabis six years ago. He suffered a herniated disc and prolonged pain, for which he was prescribed oxycodone and codeine products for several months. He wonders if cannabis can be prescribed to him now, as he is finding the cost, and the occasional lack of availability, difficult to deal with. Sam says the cannabis is useful for relieving his pain.
Clinical exam assessment area What communication strategies would you use to engage Sam? How would you develop rapport and get the clinical information you need?
How would you sensitively ask about Sam’s protective and risk factors, such as his family situation?
How might you adjust your communication if Sam became defensive or tense during the consultation? What if Sam did not speak English well?
Communication Strategies to Engage Sam
Establishing Initial Rapport
- Warm Greeting: Start with a friendly greeting and use his name to create a personal connection.
- Active Listening: Show genuine interest in his concerns by listening attentively without interrupting.
- Open Body Language: Use open and relaxed body language to create a welcoming atmosphere.
Developing Rapport and Gathering Clinical Information
- Empathy and Understanding: Express empathy for his pain and difficulties with medication costs and availability.
- “I understand how challenging chronic pain can be and how frustrating it must be to deal with medication costs and availability.”
- Open-Ended Questions: Use open-ended questions to encourage Sam to share more about his experience.
- “Can you tell me more about how the cannabis helps with your pain?”
- “What other treatments or medications have you tried for your pain?”
- Reflective Listening: Reflect back what Sam says to show you understand and to clarify information.
- “So, you find that cannabis has been helpful for managing your pain. Can you describe how it affects your daily activities?”
- Comprehensive History: Ask about his pain history, previous treatments, and current use of medications.
- “Can you walk me through the history of your pain and the treatments you have used?”
- Protective and Risk Factors: Inquire about his family situation, support system, and any potential risk factors for substance use or mental health issues.
- “How is your family coping with your pain? Do you have a good support system?”
- “Have you ever had any issues with substance use or dependency?”
Managing Defensive or Tense Reactions
- Stay Calm and Patient: Remain calm and patient if Sam becomes defensive or tense.
- Acknowledge Emotions: Acknowledge his feelings and validate his experiences.
- “I can see this is a very important and sensitive issue for you.”
- Clarify Intentions: Reassure Sam that your goal is to help him manage his pain effectively and safely.
- “My aim is to understand your situation fully so that we can find the best approach to manage your pain.”
- Offer Choices: Provide options and involve Sam in decision-making to give him a sense of control.
- “Let’s explore all the possible options together, including cannabis and other treatments.”
Adjusting Communication for Language Barriers
- Simple Language: Use clear and simple language to ensure understanding.
- Interpreter Services: If Sam does not speak English well, use professional interpreter services to facilitate communication.
- Visual Aids: Utilize visual aids, diagrams, or written materials in his preferred language.
- Check Understanding: Regularly check his understanding by asking him to repeat information or explain it back in his own words.
- “Can you tell me what you understand about this treatment?”
Clinical Exam Assessment Area
- Pain Assessment: Assess the intensity, location, and nature of Sam’s pain using a standardized pain scale (e.g., Numerical Rating Scale).
- Functional Impact: Evaluate how the pain affects his daily activities, work, and quality of life.
- Physical Examination: Conduct a thorough physical examination focusing on the spine and any areas of pain.
- Medication Review: Review his current medications, including any opioids and cannabis, for potential interactions or side effects.
- Mental Health Assessment: Screen for any signs of depression, anxiety, or substance use disorder, considering his prolonged pain and medication history.
Conclusion
To effectively engage Sam, use communication strategies that build rapport, gather comprehensive clinical information, and address protective and risk factors sensitively. Adjust your approach if he becomes defensive or if there are language barriers. Conduct a thorough clinical assessment to understand the full impact of his pain and to explore the best management options, including the potential use of prescribed cannabis.
What specific information about Sam’s substance use do you need to make an accurate assessment and develop a management plan?
What further information would you like about Sam’s past medical history? What examination would you perform?
Specific Information About Sam’s Substance Use
Current Cannabis Use
- Frequency and Dosage: How often does Sam use cannabis, and what is the typical dosage?
- Form and Source: What form of cannabis does he use (e.g., smoked, vaped, edibles) and where does he obtain it?
- Duration: How long has he been using cannabis regularly?
- Effectiveness: How effective does he find cannabis in managing his pain compared to other treatments?
- Side Effects: Has he experienced any adverse effects from cannabis use (e.g., cognitive impairment, mood changes)?
- Legal Issues: Has he encountered any legal issues related to cannabis use?
Past and Current Use of Other Substances
- Opioids: Details about his past use of oxycodone and codeine, including dosage, duration, and any issues with dependence or withdrawal.
- Alcohol: How much and how often does he consume alcohol?
- Other Drugs: Does he use any other substances, whether recreational or prescription?
- Nicotine: Does he smoke or use other tobacco products?
Substance Use History
- Initiation: When did he first start using cannabis and other substances?
- Patterns: Has his use of substances changed over time, and if so, how?
- Dependence: Any history of dependence or attempts to quit substances?
- Impact: How has substance use affected his life, including work, relationships, and mental health?
Further Information About Sam’s Past Medical History
Pain and Musculoskeletal History
- Herniated Disc: Detailed history of his herniated disc, including when it occurred, treatments received, and current status.
- Other Musculoskeletal Issues: Any other musculoskeletal problems, injuries, or surgeries.
- Chronic Pain: Duration, intensity, and management of his chronic pain condition.
Medical History
- Chronic Conditions: Any chronic medical conditions such as diabetes, hypertension, or respiratory issues.
- Mental Health: History of mental health conditions, including depression, anxiety, or any history of psychiatric treatment.
- Surgeries and Hospitalizations: Past surgeries, hospitalizations, and significant illnesses.
- Allergies: Any known allergies, particularly to medications.
- Family Medical History: Relevant family history of chronic illnesses or substance use disorders.
Examination to Perform
General Examination
- Vital Signs: Measure blood pressure, heart rate, respiratory rate, and temperature.
- General Appearance: Assess his overall physical appearance, including signs of distress, malnutrition, or neglect.
Pain Assessment
- Visual Analog Scale (VAS) or Numerical Rating Scale (NRS): Quantify the severity of his pain.
- Location and Character: Ask him to describe the location, nature (sharp, dull, throbbing), and duration of his pain.
Musculoskeletal Examination
- Spine Examination: Inspect and palpate the spine for any deformities, tenderness, or muscle spasms.
- Range of Motion: Assess the range of motion in his spine and major joints.
- Neurological Assessment: Check for any neurological deficits, including reflexes, muscle strength, and sensation in the lower limbs.
- Gait and Posture: Observe his gait and posture for any abnormalities.
Mental Health Assessment
- Mood and Affect: Assess his mood and affect during the consultation.
- Cognitive Function: Perform a brief cognitive assessment if necessary.
- Screening Tools: Use standardized screening tools for depression, anxiety, and substance use disorders (e.g., PHQ-9, GAD-7, CAGE questionnaire).
Substance Use Examination
- Signs of Substance Use: Look for signs of substance use, such as track marks, oral lesions, or signs of intoxication or withdrawal.
- Physical Impact: Assess for any physical impact of long-term substance use, including respiratory, cardiovascular, or gastrointestinal effects.
Conclusion
To make an accurate assessment and develop a management plan for Sam, gather detailed information about his substance use, including cannabis and other substances. Obtain a comprehensive past medical history focusing on his pain and musculoskeletal issues. Perform a thorough physical examination, including general assessment, pain evaluation, musculoskeletal and neurological examinations, and a mental health assessment. This approach ensures a holistic understanding of Sam’s condition and helps tailor an appropriate management plan.
What specific information about Sam’s substance use do you need to make an accurate assessment and develop a management plan?
What further information would you like about Sam’s past medical history? What examination would you perform?
Specific Information About Sam’s Substance Use
Current Cannabis Use
- Frequency and Dosage: How often does Sam use cannabis, and what is the typical dosage?
- Form and Administration: What form of cannabis does he use (e.g., smoked, vaped, edibles) and how does he administer it?
- Source and Cost: Where does he obtain the cannabis, and how much does it cost him?
- Duration: How long has he been using cannabis regularly for pain relief?
- Effectiveness: How effective does he find cannabis in managing his pain compared to other treatments he has tried?
- Side Effects: Has he experienced any adverse effects from cannabis use (e.g., cognitive impairment, mood changes, respiratory issues)?
- Consistency of Use: Has he noticed any issues with tolerance or needing to use more over time to achieve the same effect?
- Legal Concerns: Has he encountered any legal issues related to his cannabis use?
Past and Current Use of Other Substances
- Opioids (Oxycodone, Codeine): Details about his past use of opioids, including the dosage, duration, effectiveness, and any issues with dependence or withdrawal.
- Alcohol: How much and how often does he consume alcohol? Any history of alcohol misuse or dependency?
- Other Drugs: Does he use any other recreational or prescription drugs? Details on frequency, dosage, and any issues arising from their use.
- Nicotine: Does he smoke or use other tobacco products? How much and how often?
Substance Use History
- Initiation: When did he first start using cannabis and other substances?
- Patterns of Use: Has his use of substances changed over time, and if so, how?
- Dependence: Any history of dependence or attempts to quit substances? Any use of addiction treatment services or programs?
- Impact on Life: How has substance use affected his daily life, work, relationships, and mental health?
Further Information About Sam’s Past Medical History
Pain and Musculoskeletal History
- Herniated Disc: Detailed history of his herniated disc, including when it occurred, treatments received (e.g., physical therapy, surgery), and current status.
- Chronic Pain: Duration, intensity, and management strategies for his chronic pain condition. How has his pain affected his daily activities and quality of life?
General Medical History
- Chronic Conditions: Any chronic medical conditions such as diabetes, hypertension, or respiratory issues.
- Surgeries and Hospitalizations: Past surgeries, hospitalizations, and significant illnesses.
- Medications: Current and past medications, including dosages and reasons for discontinuation.
- Mental Health: History of mental health conditions, including depression, anxiety, or any psychiatric treatment. Any history of trauma or PTSD?
- Family Medical History: Relevant family history of chronic illnesses, substance use disorders, or mental health conditions.
- Allergies: Any known allergies, particularly to medications.
Examination to Perform
General Examination
- Vital Signs: Measure blood pressure, heart rate, respiratory rate, and temperature.
- General Appearance: Assess his overall physical appearance, including signs of distress, malnutrition, or neglect.
Pain Assessment
- Pain Scale: Use a standardized pain scale, such as the Numerical Rating Scale (NRS), to quantify the severity of his pain.
- Location and Character: Ask him to describe the location, nature (sharp, dull, throbbing), and duration of his pain.
- Functional Impact: Assess how his pain affects his daily activities, work, and quality of life.
Musculoskeletal Examination
- Inspection: Look for any deformities, swelling, or asymmetry in the spine and affected areas.
- Palpation: Palpate the spine and surrounding muscles for tenderness, muscle spasms, or other abnormalities.
- Range of Motion: Assess the range of motion in his spine and major joints.
- Neurological Assessment: Check for any neurological deficits, including reflexes, muscle strength, and sensation in the lower limbs.
- Gait and Posture: Observe his gait and posture for any abnormalities.
Substance Use Examination
- Signs of Substance Use: Look for signs of substance use, such as track marks, oral lesions, or signs of intoxication or withdrawal.
- Physical Impact: Assess for any physical impact of long-term substance use, including respiratory, cardiovascular, or gastrointestinal effects.
Mental Health Assessment
- Mood and Affect: Assess his mood and affect during the consultation.
- Cognitive Function: Perform a brief cognitive assessment if necessary.
- Screening Tools: Use standardized screening tools for depression, anxiety, and substance use disorders (e.g., PHQ-9, GAD-7, CAGE questionnaire).
Conclusion
To make an accurate assessment and develop a management plan for Sam, gather detailed information about his substance use, including current and past use of cannabis and other substances. Obtain a comprehensive past medical history focusing on his pain and musculoskeletal issues, as well as any chronic conditions and mental health history. Perform a thorough physical examination, including a general assessment, pain evaluation, musculoskeletal and neurological examinations, and a mental health assessment. This approach ensures a holistic understanding of Sam’s condition and helps tailor an appropriate management plan.
How would you assess the risks to Sam and to his partner and children from his drug use? What preventive activities are important for Sam?
How would you discuss harm minimisation and develop an action plan with Sam and his family?
What changes could you advocate for in your practice and community to improve care of substance-using patients?
Assessing Risks to Sam and His Partner and Children from His Drug Use
Risks to Sam
- Physical Health:
- Chronic Pain Management: Potential for inadequate pain control or exacerbation of pain.
- Side Effects: Adverse effects of cannabis, including cognitive impairment, respiratory issues (if smoked), and potential for dependence.
- Interaction with Other Medications: Risks of drug interactions with any other prescribed medications.
- Mental Health: Increased risk of anxiety, depression, and other mental health issues.
- Psychosocial Risks:
- Dependence and Addiction: Risk of developing dependence on cannabis or other substances.
- Legal Issues: Potential legal consequences of using non-prescribed cannabis.
- Occupational Impact: Impaired ability to perform work duties safely, particularly as a forklift driver.
Risks to Partner and Children
- Family Dynamics:
- Emotional Impact: Increased stress and anxiety within the family due to Sam’s substance use.
- Relationship Strain: Strained relationships between Sam and his partner, potentially leading to conflict or separation.
- Child Safety and Well-being:
- Exposure to Drug Use: Risk of children being exposed to drug use and its normalization.
- Neglect or Abuse: Potential for neglect or emotional/physical abuse if Sam’s substance use affects his behavior and parenting.
- Role Modeling: Risk of children adopting similar behaviors or substance use patterns.
Preventive Activities for Sam
- Regular Monitoring:
- Schedule regular follow-up appointments to monitor Sam’s physical and mental health, as well as his substance use.
- Health Education:
- Provide education about the risks associated with cannabis use and the importance of adhering to prescribed treatments.
- Mental Health Support:
- Screen for mental health issues and provide referrals to mental health professionals if needed.
- Lifestyle Modifications:
- Encourage healthy lifestyle changes, such as exercise, healthy eating, and stress management techniques.
- Pain Management Alternatives:
- Explore alternative pain management strategies, such as physical therapy, acupuncture, and non-opioid pain relievers.
Discussing Harm Minimisation and Developing an Action Plan
Harm Minimisation Strategies
- Safer Use:
- Educate Sam on safer ways to use cannabis, such as avoiding smoking and using vaporization or edibles instead.
- Discuss the importance of not using cannabis while performing tasks that require full attention, such as driving or operating machinery.
- Controlled Use:
- Help Sam develop strategies to control his cannabis use, such as setting limits on frequency and dosage.
- Monitoring for Dependence:
- Regularly assess for signs of cannabis dependence and provide support for reducing or stopping use if necessary.
Developing an Action Plan
- Setting Goals:
- Work with Sam to set realistic and achievable goals for managing his pain and substance use.
- Family Involvement:
- Involve Sam’s partner and family in discussions to ensure they understand the plan and can provide support.
- Support Services:
- Refer Sam and his family to support services, such as counseling, support groups, and addiction services if needed.
- Crisis Plan:
- Develop a crisis plan for situations where Sam’s substance use might escalate, including emergency contacts and steps to take.
Advocating for Changes in Practice and Community
- Education and Training:
- Provide ongoing education and training for healthcare providers on substance use disorders and harm minimisation strategies.
- Integrated Care:
- Advocate for integrated care models that include mental health and substance use services within primary care settings.
- Community Outreach:
- Engage in community outreach programs to raise awareness about substance use and available support services.
- Policy Advocacy:
- Advocate for policies that support harm minimisation, such as safe consumption spaces and needle exchange programs.
- Support Networks:
- Encourage the development of local support networks and resources for individuals and families affected by substance use.
- Access to Treatment:
- Work to improve access to evidence-based treatment options for substance use disorders in the community.
Conclusion
To assess the risks associated with Sam’s drug use, consider both the direct impact on his health and the indirect effects on his family. Implement preventive activities such as regular monitoring, health education, mental health support, and alternative pain management strategies. Engage in harm minimisation discussions and develop an action plan involving Sam and his family. Advocate for changes in practice and community to improve the care of substance-using patients by focusing on education, integrated care, community outreach, policy advocacy, support networks, and improved access to treatment.
How would you counsel Sam if you decide that cannabis is not indicated? What personal biases do you need to be aware of in managing Sam?
What are the ethical concerns for both patient and doctor in using a medication ‘off label’ when evidence of benefit is not proven in clinical trials?
Counseling Sam if Cannabis is Not Indicated
- Acknowledge His Experience
- Empathy: Show empathy for his pain and frustration.
- “I understand that chronic pain is incredibly challenging and that you’re seeking relief.”
- Explain the Decision
- Medical Rationale: Clearly explain why cannabis is not indicated based on current medical guidelines and evidence.
- “Based on the current medical guidelines and evidence, I cannot prescribe cannabis because it has not been proven to be effective and safe for your condition in clinical trials.”
- Discuss Alternatives
- Pain Management Options: Offer alternative pain management strategies, such as non-opioid medications, physical therapy, and other modalities.
- “There are several other treatments we can explore, such as physical therapy, acupuncture, and non-opioid pain relievers.”
- Provide Support
- Mental Health Resources: Offer support for any mental health issues, such as counseling or support groups.
- “I can refer you to a counselor or support group to help you manage the emotional aspects of chronic pain.”
- Create a Plan
- Action Plan: Develop a comprehensive pain management plan tailored to his needs.
- “Let’s work together to create a plan that includes different approaches to help manage your pain effectively.”
- Follow-Up
- Regular Check-Ins: Schedule regular follow-up appointments to monitor his progress and adjust the treatment plan as needed.
- “We will schedule regular follow-ups to see how you’re doing and make any necessary adjustments to your treatment.”
Personal Biases to Be Aware of in Managing Sam
- Stigma Against Substance Use:
- Awareness: Be aware of any negative biases or stigmas you may hold against cannabis or other substance use.
- Impact: Recognize how these biases can impact your judgment and interactions with Sam.
- Chronic Pain Skepticism:
- Validation: Ensure that you validate Sam’s pain experience and do not dismiss it as exaggerated or illegitimate.
- Age-Related Bias:
- Consideration: Avoid assumptions about Sam’s ability to cope with pain based on his age or occupation.
- Cultural Competence:
- Sensitivity: Be sensitive to any cultural differences that might affect Sam’s perceptions of pain and treatment.
- Personal Experiences:
- Self-Reflection: Reflect on your own experiences and how they may influence your perspective on cannabis use.
Ethical Concerns for Using Medication ‘Off Label’
Patient Concerns
- Informed Consent:
- Transparency: Ensure that Sam is fully informed about the lack of proven benefit and potential risks associated with off-label use.
- Autonomy: Respect his autonomy to make an informed decision about his treatment.
- Safety and Efficacy:
- Evidence: Be transparent about the lack of robust clinical evidence supporting the use of cannabis for his condition.
- Monitoring: Emphasize the need for careful monitoring if an off-label medication is used.
- Expectations Management:
- Realistic Expectations: Set realistic expectations about the potential benefits and limitations of the treatment.
Doctor Concerns
- Professional Responsibility:
- Guidelines: Adhere to clinical guidelines and standards of care to ensure that the treatment is in the patient’s best interest.
- Ethical Duty: Balance the ethical duty to alleviate suffering with the need to provide treatments supported by evidence.
- Legal Implications:
- Compliance: Be aware of the legal implications of prescribing off-label medications and ensure compliance with local regulations.
- Documentation: Maintain thorough documentation of the rationale for off-label use and the informed consent process.
- Risk of Harm:
- Patient Safety: Prioritize patient safety and avoid treatments that could potentially cause more harm than benefit.
- Monitoring: Implement a robust monitoring plan to detect and address any adverse effects promptly.
- Professional Integrity:
- Ethical Practice: Uphold the principles of ethical medical practice, including beneficence, non-maleficence, and respect for patient autonomy.
Conclusion
When counseling Sam about the decision not to prescribe cannabis, it is important to show empathy, clearly explain the medical rationale, discuss alternative treatments, provide support, create a comprehensive plan, and schedule regular follow-ups. Be aware of personal biases that may affect your management of Sam, including stigma against substance use, skepticism about chronic pain, age-related biases, cultural sensitivity, and personal experiences. Ethical concerns for using medication off-label include ensuring informed consent, prioritizing patient safety, managing expectations, adhering to professional guidelines, complying with legal requirements, and maintaining professional integrity.
Is Sam able to access prescribed cannabis? How could you check his drug use history further?
How would you advise Sam about the regulatory issues involved in his current and potential substance/medication use; for example, with respect to his occupation or driving?
Is Sam Able to Access Prescribed Cannabis?
Legal Status in Australia
- Medical Cannabis Regulations: In Australia, medical cannabis is legal under certain conditions and can be prescribed by a registered medical practitioner.
- Criteria for Prescription: The prescription of medical cannabis typically requires:
- Evidence of a condition that may benefit from cannabis treatment.
- Failure of conventional treatments to adequately manage the condition.
- Consideration of the potential benefits and risks.
Process for Accessing Prescribed Cannabis
- Consultation with GP: Sam would need to have a detailed consultation with his GP to assess whether he meets the criteria for medical cannabis.
- Specialist Referral: In some cases, a referral to a specialist or pain clinic might be necessary for further assessment and approval.
- TGA Approval: The GP or specialist may need to apply to the Therapeutic Goods Administration (TGA) for approval under the Special Access Scheme (SAS) or the Authorised Prescriber Scheme.
- Prescription: If approved, Sam would receive a prescription and could obtain medical cannabis from a licensed dispensary.
Checking Sam’s Drug Use History Further
- Medical Records Review: Review Sam’s medical records for a history of prescribed medications and any notes on substance use.
- Prescription Monitoring Program (PMP): Utilize the state’s Prescription Monitoring Program to check for prescriptions of controlled substances.
- Detailed History Taking:
- Direct Questions: Ask Sam detailed questions about his substance use, including frequency, dosage, and sources of substances.
- Previous Treatments: Inquire about previous treatments for pain and any issues with dependence or withdrawal.
- Urine Drug Screening: Consider performing a urine drug screen to detect the presence of various substances.
- Collateral Information: With Sam’s consent, gather information from other healthcare providers or family members who might have insights into his substance use.
Advising Sam About Regulatory Issues
Occupational Considerations
- Workplace Policies: Advise Sam to check his employer’s policies on substance use, particularly regarding cannabis.
- Safety-Sensitive Positions: Highlight that as a forklift driver, he holds a safety-sensitive position where impairment could pose significant risks.
- Legal Obligations: Inform Sam about any legal obligations to disclose substance use to his employer, especially if it could affect his ability to perform his job safely.
Driving Regulations
- Legal Limits: Explain that driving under the influence of cannabis is illegal and that it is subject to strict enforcement.
- Detection: Discuss the fact that THC, the psychoactive component of cannabis, can be detected in saliva, blood, and urine tests, which can be conducted by police.
- Impairment: Emphasize the potential for cannabis to impair driving ability, increasing the risk of accidents and legal consequences.
General Regulatory Issues
- Prescription Requirements: Explain the requirements for legally obtaining medical cannabis through a prescription and the importance of adhering to these regulations.
- Use of Non-Prescribed Cannabis: Warn about the legal risks and potential health hazards of using non-prescribed cannabis.
- Record-Keeping: Encourage Sam to maintain accurate records of his medical cannabis use, including dosages and effects, to facilitate ongoing assessment and management.
- Drug Interactions: Discuss potential interactions between cannabis and other medications Sam may be taking.
Example Discussion with Sam
“Sam, I understand that you are seeking relief from your chronic pain, and I’m here to help you explore all available options. Currently, medical cannabis can be legally prescribed in Australia if certain criteria are met, and it might be an option for you. However, we need to carefully assess your situation, including your past and current substance use.
I’d like to review your medical records and possibly perform a urine drug screen to get a clearer picture of your substance use history. It’s also important to consider the regulatory issues involved. As a forklift driver, using cannabis could affect your job because it’s a safety-sensitive position. Additionally, driving under the influence of cannabis is illegal and could lead to serious legal consequences.
We need to ensure that any treatment plan we develop not only addresses your pain but also keeps you safe and complies with legal requirements. Let’s work together to explore the best options for your pain management while considering these important factors.”
Conclusion
Sam may be able to access prescribed cannabis if he meets the necessary criteria and goes through the appropriate process with his GP and possibly a specialist. To further check his drug use history, you can review medical records, use prescription monitoring programs, take a detailed history, perform urine drug screening, and gather collateral information. When advising Sam about regulatory issues, consider occupational considerations, driving regulations, and general legal requirements for substance use. Ensuring Sam understands the implications of his substance use, particularly regarding his occupation and legal responsibilities, is crucial for developing a safe and effective management plan.
What clinical tools could help you manage Sam?
Clinical Tools to Help Manage Sam
Pain Assessment Tools
- Visual Analog Scale (VAS):
- A simple tool where Sam can mark his pain intensity on a 10 cm line ranging from “no pain” to “worst pain imaginable.”
- Numeric Rating Scale (NRS):
- Sam rates his pain on a scale from 0 (no pain) to 10 (worst pain imaginable).
- Brief Pain Inventory (BPI):
- A comprehensive tool that assesses the severity of pain and its impact on daily functions.
- McGill Pain Questionnaire (MPQ):
- Provides a detailed qualitative and quantitative measure of pain.
Substance Use Assessment Tools
- Alcohol, Smoking and Substance Involvement Screening Test (ASSIST):
- A WHO-developed tool that helps to identify the level of substance use and associated risks.
- Drug Abuse Screening Test (DAST):
- A brief self-report tool to screen for drug use and related problems.
- CAGE Questionnaire:
- A simple tool to screen for alcohol dependence, with potential adaptation for other substances.
- AUDIT (Alcohol Use Disorders Identification Test):
- Assesses alcohol consumption, drinking behaviors, and alcohol-related problems.
Mental Health Screening Tools
- Patient Health Questionnaire-9 (PHQ-9):
- Screens for the presence and severity of depression.
- Generalized Anxiety Disorder-7 (GAD-7):
- Screens for the severity of generalized anxiety disorder.
- Post-Traumatic Stress Disorder Checklist (PCL-5):
- Assesses the presence and severity of PTSD symptoms.
Functional Assessment Tools
- Oswestry Disability Index (ODI):
- Measures the degree of disability and functional impairment due to lower back pain.
- Roland-Morris Disability Questionnaire (RMDQ):
- Assesses the impact of back pain on physical functioning.
Risk Assessment Tools
- Opioid Risk Tool (ORT):
- Assesses the risk of opioid addiction in patients who are being considered for opioid therapy.
- Screener and Opioid Assessment for Patients with Pain (SOAPP):
- Evaluates the risk of opioid abuse in chronic pain patients.
Medication Monitoring Tools
- Prescription Monitoring Programs (PMP):
- State-run programs that track the prescribing and dispensing of controlled substances to monitor and prevent drug misuse.
- Medication Management Apps:
- Digital tools that help patients track their medication usage and provide reminders.
Communication and Documentation Tools
- SOAP Notes (Subjective, Objective, Assessment, Plan):
- A structured method for documenting patient encounters comprehensively.
- Shared Decision-Making Aids:
- Tools that facilitate discussion and decision-making between Sam and his healthcare provider about treatment options.
- Electronic Health Records (EHR):
- Comprehensive digital records that facilitate information sharing and coordination of care.
Referral and Support Tools
- Referral Templates:
- Standardized forms to facilitate referrals to specialists, pain clinics, or mental health services.
- Community Resource Lists:
- Compiled lists of local support services, such as counseling, support groups, and addiction services.
Conclusion
A combination of these clinical tools can help manage Sam effectively by providing comprehensive assessments, monitoring his condition, and facilitating communication and decision-making. Using pain assessment tools, substance use screening tools, mental health screening tools, functional assessment tools, risk assessment tools, medication monitoring tools, communication and documentation tools, and referral and support tools will enable a holistic and tailored approach to his care.
What if you found out that Sam’s wife also smoked cannabis?
What if Sam later admitted to you that he was also on an opioid substitution program?
What action would you take?
If Sam’s Wife Also Smokes Cannabis
Assess the Situation
- Explore Her Use:
- Ask about the frequency, duration, and context of her cannabis use.
- Assess if her use is recreational, medicinal, or problematic.
- “Can you tell me more about your wife’s cannabis use? How often does she use it, and has she mentioned why she uses it?”
- Evaluate Family Dynamics:
- Discuss how their cannabis use impacts family life, including their children.
- Assess if their cannabis use is contributing to any family or relationship issues.
- Health and Safety:
- Assess if there are any health concerns related to her cannabis use.
- Discuss the impact of cannabis smoke on household members, especially children.
Provide Guidance and Support
- Health Education:
- Educate both Sam and his wife on the potential health risks associated with cannabis use, especially smoking.
- Discuss safer alternatives if they are using cannabis for medicinal purposes, such as vaporizers or edibles.
- Referral to Support Services:
- Offer information about local support services or counseling for substance use.
- Refer to family therapy if there are concerns about family dynamics or relationship issues.
- Harm Reduction Strategies:
- Discuss harm reduction strategies, such as not smoking indoors and keeping cannabis out of reach of children.
- Encourage them to monitor their use and seek help if they experience dependence or other issues.
If Sam Admits to Being on an Opioid Substitution Program
Immediate Actions
- Assess Current Status:
- Ask about his opioid substitution program, including what medication he is taking (e.g., methadone, buprenorphine), dosage, and how long he has been on the program.
- “Can you tell me more about your opioid substitution program? What medication are you taking, and how is it going for you?”
- Evaluate Risk of Poly-Substance Use:
- Assess the potential interactions and risks of using cannabis alongside his opioid substitution medication.
- Evaluate the potential for substance use disorders and the impact on his pain management and overall health.
- Coordinate Care:
- Contact the clinic or provider managing his opioid substitution program to coordinate care and ensure all providers are aware of his substance use.
- Obtain Sam’s consent to share relevant information between providers.
Long-Term Management Plan
- Comprehensive Substance Use Assessment:
- Conduct a thorough assessment of all substances he is using, including cannabis, opioids, and any other substances.
- Use screening tools such as the ASSIST or DAST to evaluate the extent of his substance use.
- Integrated Care Approach:
- Develop an integrated care plan that addresses both his pain management and substance use.
- Include multidisciplinary support, such as addiction specialists, pain management experts, and mental health professionals.
- Regular Monitoring and Support:
- Schedule regular follow-up appointments to monitor his progress, adjust treatment as necessary, and provide ongoing support.
- “We’ll need to see you regularly to ensure that your pain and substance use are managed effectively and safely. Let’s set up a follow-up plan.”
- Patient Education and Counseling:
- Educate Sam about the potential risks and interactions of using cannabis with his opioid substitution medication.
- Provide counseling or refer to counseling services to support his substance use recovery and overall well-being.
- Harm Reduction and Safety Planning:
- Discuss harm reduction strategies to minimize the risks associated with poly-substance use.
- Develop a safety plan that includes emergency contacts and steps to take if he experiences adverse effects or relapses.
Conclusion
If Sam’s wife also smokes cannabis, assess her use, evaluate the impact on family dynamics, and provide education and support. If Sam admits to being on an opioid substitution program, assess his current status, evaluate the risks of poly-substance use, coordinate care with his opioid substitution provider, and develop a comprehensive, integrated management plan that includes regular monitoring, patient education, and harm reduction strategies. This holistic approach ensures that both Sam and his family receive the support and care they need to manage substance use and related health issues effectively.
What do you need to look out for in monitoring Sam if he engages in treatment with you?
How would you identify drug-induced psychosis?
What would be your management if Sam presented to an appointment intoxicated or in withdrawal?
Monitoring Sam if He Engages in Treatment
Key Areas to Monitor
- Pain Management:
- Pain Levels: Regularly assess Sam’s pain levels using tools like the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS).
- Functionality: Evaluate how pain affects his daily activities and quality of life.
- Substance Use:
- Cannabis Use: Monitor the frequency, dosage, and impact of cannabis use.
- Opioid Use: Track his adherence to the opioid substitution program and any other opioid use.
- Other Substances: Check for use of other substances, including alcohol and nicotine.
- Mental Health:
- Mood and Behavior: Watch for changes in mood, behavior, and signs of mental health issues such as anxiety or depression.
- Screening Tools: Use tools like the PHQ-9 for depression and GAD-7 for anxiety.
- Adherence to Treatment Plan:
- Medication Compliance: Ensure he is taking prescribed medications correctly.
- Follow-Up Appointments: Track his attendance at scheduled appointments and any missed visits.
- Side Effects and Complications:
- Adverse Effects: Monitor for side effects of prescribed medications and cannabis use, such as cognitive impairment or respiratory issues.
- Interactions: Be vigilant for potential interactions between different substances he is using.
Regular Assessments
- Physical Examination: Conduct periodic physical exams to check for signs of health deterioration.
- Laboratory Tests: Order relevant blood tests to monitor liver function, renal function, and other parameters if indicated.
- Urine Drug Screens: Perform urine drug screens to monitor for adherence to the opioid substitution program and detect the use of other substances.
Identifying Drug-Induced Psychosis
Symptoms of Drug-Induced Psychosis
- Hallucinations:
- Auditory: Hearing voices or sounds that aren’t there.
- Visual: Seeing things that aren’t present.
- Delusions:
- Paranoia: Believing others are out to harm them.
- Grandiosity: Believing they have special powers or abilities.
- Disorganized Thinking:
- Confusion: Difficulty organizing thoughts or following a conversation.
- Incoherence: Speaking in a way that is hard to understand.
- Behavioral Changes:
- Agitation: Increased irritability or restlessness.
- Aggression: Uncharacteristic aggressive behavior.
- Mood Disturbances:
- Euphoria: Excessive, inappropriate happiness.
- Depression: Sudden, severe depressive episodes.
Assessment
- History: Take a detailed history of recent substance use, including the type, amount, and duration.
- Mental Status Examination: Conduct a thorough mental status examination to assess orientation, memory, thought processes, and perception.
- Collateral Information: Gather information from family members or caregivers about recent changes in behavior or mood.
Management if Sam Presents Intoxicated or in Withdrawal
If Sam is Intoxicated
- Immediate Safety:
- Calm Environment: Ensure a calm and safe environment to reduce agitation.
- Supervision: Have a staff member or trusted person stay with Sam.
- Assessment:
- Vital Signs: Check vital signs to assess his immediate health status.
- Level of Consciousness: Evaluate his level of consciousness and responsiveness.
- Supportive Care:
- Hydration: Offer water or oral rehydration solutions if appropriate.
- Observation: Monitor him closely until the effects of intoxication wear off.
- Referral:
- Emergency Services: If he shows signs of severe intoxication or overdose, refer him to emergency services immediately.
If Sam is in Withdrawal
- Symptom Assessment:
- Withdrawal Symptoms: Identify symptoms such as sweating, tremors, agitation, nausea, vomiting, and anxiety.
- Medication:
- Withdrawal Management: Administer appropriate medications to manage withdrawal symptoms, such as benzodiazepines for alcohol withdrawal or buprenorphine for opioid withdrawal.
- Monitoring:
- Vital Signs: Regularly monitor vital signs to detect any complications.
- Reassurance: Provide reassurance and support to help him cope with withdrawal symptoms.
- Referral and Support:
- Detoxification Services: Refer to a detoxification center if withdrawal symptoms are severe.
- Counseling and Support: Arrange for counseling and support services to assist with his recovery.
Conclusion
Monitoring Sam effectively requires regular assessments of his pain management, substance use, mental health, and adherence to the treatment plan. Identifying drug-induced psychosis involves recognizing symptoms such as hallucinations, delusions, disorganized thinking, and behavioral changes. Managing intoxication or withdrawal involves ensuring immediate safety, assessing symptoms, providing supportive care, and making appropriate referrals. By using these clinical tools and approaches, you can provide comprehensive and effective care for Sam.