Domain – Addiction medicine (Guiding topics)

Effective Communication with Substance-Using Patients

Use Effective Communication Skills: As a medical professional, it’s crucial to use effective communication skills to support the health of substance-using patients. This includes using non-stigmatising language and maintaining a positive attitude. Stigmatising language can discourage patients from seeking help and can worsen their mental health. For example, instead of referring to someone as an “addict,” use terms like “person with substance use disorder.” Similarly, avoid using terms like “clean” or “dirty” to describe drug tests. A positive attitude can build trust and make patients feel valued and respected.

Identify and Manage Barriers to Communication and Engagement: Understanding and addressing barriers to communication is essential. Patients may face several challenges, such as:

• Lack of Knowledge or Confidence for Change
  • Example: A patient may not realize the extent of harm caused by their alcohol use and feels incapable of quitting.
  • Management:
    • Education: Use educational materials tailored to the patient’s level of understanding. Provide information about the health risks of substance use and the benefits of quitting.
    • Motivational Interviewing: Use motivational interviewing techniques to explore the patient’s ambivalence about change and to enhance their motivation to quit.
    • Goal Setting: Help the patient set achievable goals and celebrate small successes to build their confidence in making changes.
• Low Health Literacy
  • Example: A patient struggles to understand the instructions for their medication or the importance of follow-up appointments.
  • Management:
    • Simple Language: Communicate using simple, clear language. Avoid medical jargon.
    • Visual Aids: Use diagrams, pictures, and videos to explain concepts.
    • Teach-Back Method: Ask the patient to repeat the information back to you in their own words to ensure they understand.
    • Written Materials: Provide easy-to-read written materials that the patient can refer to later.
• Coercion
  • Example: A patient mandated to treatment by the court feels resentful and uncooperative.
  • Management:
    • Acknowledge Feelings: Recognize and validate the patient’s feelings about being coerced into treatment.
    • Build Rapport: Establish a trusting relationship by showing empathy and respect.
    • Collaborative Approach: Involve the patient in decision-making as much as possible to give them a sense of control.
    • Motivation Enhancement: Focus on the patient’s personal goals and values to find intrinsic motivations for engaging in treatment.
• Past Trauma or Violence
  • Example: A patient with a history of abuse is hesitant to engage in treatment due to trust issues.
  • Management:
    • Trauma-Informed Care: Adopt a trauma-informed approach that emphasizes safety, trustworthiness, and empowerment.
    • Sensitive Communication: Be gentle and non-judgmental in your interactions.
    • Support Services: Connect the patient with counseling and support services that specialize in trauma.
    • Consistency: Provide consistent and predictable care to build trust over time.
• Cost of Treatment
  • Example: A patient cannot afford the cost of their prescribed medication or therapy sessions.
  • Management:
    • Discuss Financial Options: Inform the patient about bulk-billing options, sliding scale fees, and any available financial assistance programs.
    • Community Resources: Refer the patient to community resources and support services that offer free or low-cost care.
    • Government Programs: Assist the patient in applying for government-funded programs like Medicare and the Pharmaceutical Benefits Scheme (PBS) that can reduce costs.
• Lack of Family and Community Support
  • Example: A patient feels isolated and lacks a support system to aid in their recovery.
  • Management:
    • Encourage Support Networks: Encourage the patient to connect with family, friends, and peer support groups.
    • Support Groups: Refer the patient to local support groups such as Alcoholics Anonymous or Narcotics Anonymous.
    • Community Engagement: Suggest community activities or volunteering as a way to build social connections.
    • Professional Support: Provide referrals to social workers or counselors who can help the patient develop a support network.

Motivational Interviewing and Brief Interventions

Perform Motivational Interviewing: Motivational interviewing is a patient-centered approach that enhances motivation to change by exploring and resolving ambivalence. This technique is informed by the cycle-of-change model, which includes stages like precontemplation, contemplation, preparation, action, and maintenance. Effective motivational interviewing involves:

• Exploring Reasons for Change and Preventing Relapse: Help patients articulate their reasons for wanting to change and develop strategies to avoid relapse.
• Advising on Safe Use of Substances: Provide practical advice on harm reduction, such as safe alcohol consumption, smoking cessation, and safer injecting practices.
• Providing Harm-Minimisation Advice: Tailor harm-reduction advice to the specific substances the patient uses.
• Offering Preconception and Prenatal Advice: Educate patients about the risks of substance use during pregnancy and offer guidance on safer alternatives.
• Preventing Suicide: Screen for suicidal ideation and provide appropriate interventions, including referrals to mental health services.
• Empowering Patients: Provide information and resources that enable patients to take control of their health and develop life skills.

Proactive Identification and Assessment of Substance Use

Regular Screening for Substance Use: Regularly ask patients about their use of nicotine, alcohol, illicit drugs, and prescribed medications, such as sedatives and stimulants. Use validated screening tools like the AUDIT-C for alcohol use and the DAST-10 for drug use.

Assessing Substance Use: When a patient reports substance use, assess the type, amount, and circumstances of use. Inquire about the effects of substances on their physical and mental health. Perform a physical examination to identify signs of substance use, intoxication, and withdrawal, such as track marks from injecting drugs or tremors from alcohol withdrawal.

Managing Acute Health Issues and Chronic Conditions

Managing Acute Health Issues: Safely address acute health issues related to substance use, such as overdoses, acute withdrawal syndromes, and drug-induced psychosis. Provide immediate medical care and refer patients to appropriate services for ongoing support.

Chronic Management: Treat substance use as a chronic health condition, recognizing the potential for relapse and the need for long-term management. Conditions to manage include:

• Acute Intoxication and Overdose: Provide emergency care and use medications like naloxone for opioid overdoses.
• Acute Withdrawal Syndromes: Administer medications to alleviate withdrawal symptoms and prevent complications.
• Drug-Induced Psychosis: Manage with antipsychotic medications and psychiatric care.
• Mental Health Conditions: Address comorbid mental health issues like depression and anxiety.
• Medical Comorbidities: Treat conditions such as hepatitis C and B, HIV, liver disease, thrombophlebitis, sexually transmissible infections, and cardiovascular disease.
• Social Dysfunction: Address the broader social impacts of substance use, including occupational, relational, financial, and legal issues.

Preventive Care and Evidence-Based Treatments

Provide Preventive Care: Ensure substance-using patients receive comprehensive preventive care, including regular health checks, routine screening for infectious diseases, and up-to-date vaccinations, particularly for hepatitis B. Special attention is needed for pregnant patients to prevent adverse outcomes for both mother and child.

Preventive Care

1. Education and Awareness Programs:
   • Public health campaigns to raise awareness about the risks of substance abuse.
   • School-based programs targeting young people to prevent the initiation of substance use.
2. Screening and Early Intervention:
   • Routine screening in primary care settings using tools like AUDIT (Alcohol Use Disorders Identification Test) and DUDIT (Drug Use Disorders Identification Test).
   • Brief interventions for individuals identified as at risk.
3. Policy and Regulation:
   • Regulations on alcohol and tobacco sales, including age restrictions and marketing limitations.
   • Harm reduction policies, such as needle exchange programs and supervised injecting facilities.
4. Community Support Programs:
   • Community-based initiatives to support individuals and families affected by substance use.
   • Peer support groups and networks to provide ongoing assistance and prevent relapse.
5. Regular Health Checks
   • Routine Screening for Infectious Diseases:
     • Universal screening for hepatitis B in pregnant women is crucial to prevent mother-to-child transmission (MTCT) and ensure timely interventions (Yussf et al., 2023).
     • Screening for other infectious diseases such as HIV and syphilis is also part of standard prenatal care (Loarec et al., 2021).
   • Hepatitis B Vaccination:
     • Universal infant hepatitis B vaccination is recommended to prevent the disease and reduce long-term health risks (Thompson & Oman, 1996).
     • Hepatitis B vaccination and immunoglobulin should be administered within 12 hours of birth for infants born to HBV-positive mothers to prevent perinatal transmission (Dunkelberg et al., 2014).
   • Special Attention for Pregnant Patients:
     • Preventive Measures for Hepatitis B:
       • Pregnant women should be screened for hepatitis B during their first prenatal visit and again during labor if they have ongoing risk factors (Lam et al., 2010).
       • Infants of HBV-positive mothers should receive hepatitis B immune globulin (HBIG) and hepatitis B vaccine within 12 hours of birth (Chen et al., 2017).
   • Routine Vaccinations:
     • Influenza and pertussis vaccinations should be administered to pregnant women to protect both mother and child from these infections (Yussf et al., 2023).

Evidence-Based Treatments

Pharmacological Treatments

1. Opioid Use Disorder (OUD):
   • Methadone: A long-acting opioid agonist used in opioid substitution therapy.
   • Buprenorphine: A partial opioid agonist available alone or in combination with naloxone (Suboxone) to reduce misuse potential.
   • Naltrexone: An opioid antagonist that blocks the effects of opioids and is used in relapse prevention.
2. Alcohol Use Disorder (AUD):
   • Naltrexone: Reduces the pleasurable effects of alcohol and decreases craving.
   • Acamprosate: Helps maintain abstinence by modulating neurotransmitter systems.
   • Disulfiram: Causes unpleasant reactions when alcohol is consumed, promoting abstinence.
3. Nicotine Dependence:
   • Nicotine Replacement Therapy (NRT): Includes patches, gums, lozenges, and inhalers to reduce withdrawal symptoms.
   • Varenicline (Chantix): A partial agonist at nicotinic receptors, reducing cravings and withdrawal symptoms.
   • Bupropion (Zyban): An atypical antidepressant that also helps reduce nicotine cravings and withdrawal symptoms.

Non-Pharmacological Treatments

1. Behavioral Therapies:
   • Cognitive-Behavioral Therapy (CBT): Helps patients recognize and change maladaptive behaviors and thought patterns.
   • Motivational Interviewing (MI): Enhances a patient’s motivation to change by exploring and resolving ambivalence.
   • Contingency Management (CM): Provides tangible rewards for positive behaviors, such as maintaining abstinence.
2. Psychosocial Interventions:
   • 12-Step Programs: Such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), which offer peer support and a structured approach to recovery.
   • Family Therapy: Involves family members in the treatment process to address dysfunctional dynamics and improve support systems.
3. Integrated Treatment Programs:
   • Residential Rehabilitation: Provides intensive, structured care in a residential setting.
   • Outpatient Programs: Offer flexible treatment options that allow patients to continue with daily activities while receiving care.
4. Complementary Therapies:
   • Mindfulness-Based Interventions: Such as Mindfulness-Based Relapse Prevention (MBRP) to help patients manage cravings and stress.
   • Exercise and Physical Activity: Shown to improve mood and reduce substance use.

Implementation and Accessibility

Australia’s approach to addiction treatment involves collaboration between government bodies, healthcare providers, and community organizations to ensure accessible and comprehensive care. Key strategies include:

• Medicare and Public Health Funding: Coverage for addiction treatment services under Medicare and public health programs.
• Training and Workforce Development: Ensuring healthcare providers are trained in addiction medicine and evidence-based practices.
• Research and Continuous Improvement: Ongoing research to identify effective treatments and refine existing protocols.

Multidisciplinary Care and Behavioral Addictions

Engage in Multidisciplinary Care: Work collaboratively with other healthcare providers, social workers, and community agencies to provide holistic care. This team-based approach ensures that all aspects of a patient’s health and well-being are addressed.

Understand and Manage Behavioral Addictions: Recognize and treat behavioral addictions, such as gambling, which can co-occur with substance use disorders. Use similar strategies, including counseling and support groups, to help patients manage these behaviors.

Community Health and Advocacy

Prevalence of Substance Use and Behavioural Addictions

In Australia, the prevalence of substance use disorders and behavioural addictions remains a significant public health issue. According to the Australian Institute of Health and Welfare (AIHW), approximately 3% of Australians aged 16-85 years had a substance use disorder in the past 12 months. The most commonly used substances include alcohol, tobacco, and cannabis. Additionally, behavioural addictions, such as gambling, are prevalent and often co-occur with substance use disorders​​​​.

Peak Age Incidence of Addictions

The peak age incidence for substance use disorders in Australia is typically among young adults. Data indicate that individuals aged 18-29 are most likely to engage in risky substance use behaviors. For instance, alcohol and illicit drug use are most prevalent in this age group, contributing significantly to the overall burden of disease and injury in the population​​​​.

Impact of Substance Use/Behavioural Addiction

Substance use and behavioural addictions have profound impacts on individuals, families, and the community. These impacts include:

• Individuals: Substance use can lead to a range of health issues, including mental health disorders, chronic diseases (e.g., liver disease, cardiovascular conditions), and acute conditions like overdoses. Behavioural addictions can cause significant psychological distress and financial hardship.
• Families: Addiction often strains family relationships, leading to emotional stress, financial difficulties, and in some cases, domestic violence. Family members may also suffer from neglect or abuse.
• Community: At the community level, substance use and behavioural addictions contribute to increased healthcare costs, loss of productivity, and higher rates of crime and social disintegration​​​​.

Special Needs of High-Risk Groups

Certain groups in Australia are at higher risk of substance use and behavioural addictions and have unique needs:

• Aboriginal and Torres Strait Islander Peoples: This group experiences higher rates of substance use and related harms, partly due to socio-economic disadvantages and historical trauma. Culturally sensitive services and support are essential​​.
• People with Mental Health Conditions: There is a high comorbidity between mental health disorders and substance use. Integrated care that addresses both mental health and substance use is crucial​​.
• LGBTIQ+ People: This population often faces discrimination and stigma, contributing to higher rates of substance use and mental health issues. Inclusive and supportive healthcare services are needed​​.
• Culturally and Linguistically Diverse Populations: Language barriers and cultural differences can hinder access to treatment. Providing culturally appropriate services is important for effective care.
• People Who Inject Drugs: This group is at high risk of infectious diseases, overdoses, and other health complications. Harm reduction strategies, such as needle exchange programs and supervised injecting facilities, are vital​​.
• Sex Workers: They face unique occupational hazards and stigma, necessitating specialized support services.
• People Recently Released from Prison: This group is vulnerable to relapse and health complications post-release. Continuity of care and support in the transition back to the community are critical.
• Rural Population: Access to healthcare services is often limited in rural areas, making it challenging for individuals to receive timely and appropriate care. Telehealth and mobile health services can help bridge this gap.

Health Advocacy and Community Support

Health professionals can advocate for supportive environments and policies that expand services and reduce stigma around addiction. Community education initiatives can raise awareness and promote understanding of substance use disorders and behavioural addictions. Facilitating informed consent and ensuring ethical treatment practices are also vital components of effective advocacy​​​​.

Treatment Consent and Regulations

Facilitate Informed Consent: Ensure patients understand their treatment options and provide informed consent. Address any capacity issues and manage refusals of treatment appropriately.

Observe Recall and Follow-Up Protocols: In Australian general practice, implementing recall and follow-up protocols is essential for monitoring the progress of patients with substance use and behavioral addictions. Regular check-ins help prevent relapse and provide ongoing support. Here are some examples of such protocols:

1. Scheduled Follow-Up Appointments:
   • Initial Intensive Follow-Up: Schedule more frequent visits (e.g., weekly or bi-weekly) immediately after the patient begins treatment to monitor early progress and address any emerging issues.
   • Regular Check-Ins: Transition to monthly follow-ups as the patient stabilizes. Use these sessions to assess adherence to treatment, discuss any side effects of medications, and provide ongoing counseling.
2. Automated Reminder Systems:
   • SMS and Email Reminders: Use automated systems to send reminders for upcoming appointments and medication refills. These systems can improve adherence to scheduled visits and medication regimes.
   • Phone Calls: Implement a protocol for staff to call patients who miss appointments to reschedule and check on their well-being.
3. Use of Electronic Health Records (EHRs):
   • Flagging High-Risk Patients: Utilize EHRs to flag patients with substance use disorders. This ensures that they are consistently followed up according to their care plan.
   • Recall Systems: Set up recall prompts within the EHR to remind clinicians when patients are due for follow-up appointments or screenings.
4. Interdisciplinary Team Meetings:
   • Case Conferences: Regularly hold interdisciplinary team meetings to discuss the progress of patients with substance use disorders. These meetings should include GPs, mental health professionals, and social workers to ensure a comprehensive approach to patient care.
5. Monitoring Treatment Plans:
   • Reviewing Medication Adherence: Regularly review the patient’s medication adherence and make necessary adjustments to the treatment plan.
   • Behavioral Health Assessments: Continuously assess the patient’s mental health status and provide appropriate interventions, such as counseling or referral to a psychiatrist if needed.
6. Patient Self-Monitoring Tools:
   • Diaries and Logs: Encourage patients to keep a diary or log of their substance use, mood, and triggers. Review these logs during follow-up appointments to tailor the treatment plan accordingly.
   • Mobile Health Apps: Recommend apps that help patients track their progress and provide educational resources on managing addiction.

Follow Prescribing Regulations

Adhering to regulations related to prescribing medications to drug-dependent patients is critical to ensure their safety and compliance with legal requirements. Here are key practices:

1. Understanding Legal Requirements:
   • Regulatory Guidelines: Stay updated on federal and state regulations regarding the prescription of controlled substances. The Therapeutic Goods Administration (TGA) and state health departments provide guidelines on prescribing opioids, benzodiazepines, and other controlled drugs.
   • Prescriber Registration: Ensure you are registered with the appropriate state authorities if required for prescribing certain medications (e.g., opioids).
2. Safe Prescribing Practices:
   • Prescription Monitoring Programs (PMPs): Use the Prescription Shopping Information Service (PSIS) and other state-based PMPs to track patients’ prescription histories and prevent doctor shopping.
   • Risk Assessment: Conduct thorough assessments to evaluate the risk of substance misuse before initiating treatment with potentially addictive medications.
3. Patient Agreements:
   • Treatment Contracts: Implement treatment agreements that outline the responsibilities of the patient and the prescriber. These contracts can include agreements on medication use, adherence to treatment plans, and regular urine drug screenings.
   • Informed Consent: Ensure patients understand the risks and benefits of their medications and obtain informed consent before starting treatment.
4. Regular Monitoring and Reviews:
   • Medication Reviews: Schedule regular reviews of the patient’s medication regimen to assess its efficacy and safety. Adjust dosages or switch medications as necessary.
   • Urine Drug Screens: Use urine drug screenings to monitor adherence to prescribed medications and detect any illicit drug use.
5. Multidisciplinary Collaboration:
   • Coordinated Care: Work with pharmacists, mental health professionals, and addiction specialists to provide comprehensive care for patients with substance use disorders.
   • Referral Systems: Establish a referral system for patients who need specialized addiction treatment or mental health services.
6. Documentation:
   • Accurate Record-Keeping: Maintain detailed records of all prescriptions, patient assessments, and follow-up appointments. This documentation is crucial for legal compliance and continuity of care.

By integrating these practices into your clinical approach, you can provide comprehensive, compassionate, and effective care to substance-using patients, ultimately improving their health outcomes and quality of life.