3.1. CONDUCTING AN ASSESSMENT
Assessment is the process of obtaining information about the patient's drug use and how it is affecting his or her life. It is an essential part of treatment and care for people who use drugs.
The person conducting the assessment should be a healthcare worker – a doctor, nurse, psychologist or other person with a health-related qualification.
It is important that the information obtained in the assessment is honest and accurate. But, talking about drug use can be difficult. Patients may be reluctant to talk about their drug use. They may be embarrassed, or they may fear punishment if they disclose drug use. The patient may be under the influence of drugs (intoxicated) on their admission to the closed setting, in which case they may not be able to answer the assessment questions accurately. Hence, before commencing the assessment, it is important to do three things:
Is the patient able to complete the assessment? If the patient is under the influence of drugs, including alcohol, it may be better to wait a few hours before assessing the patient. If the patient is in withdrawal and not able to answer questions, they should be provided with symptomatic treatment as required and allowed to stabilise before the assessment is completed.
Establish rapport with the patient. If you just start asking questions, the patient is unlikely to answer honestly. Instead, spend a few minutes on ‘small talk’. Introduce yourself, and ask the patient for his or her name. Ask an open-ended, non-threatening question, such as “How are you feeling today?”, and pay attention to the patient's response. The aim is to show the patient that you are genuinely interested in, and have empathy for, his or her situation.
Explain the assessment process to the patient. During an assessment, the patient may be asked to reveal very personal and private information. It is important that you explain why you are asking these questions, and what you will do with the information that the patient gives you. For example, “I'm going to ask you some questions about your drug use. We need to know this information so that we know what withdrawal symptoms to prepare you for, and also so that we can plan your treatment”. Reassure the patient that the assessment is confidential. Before you begin the assessment, ask the patient if he or she has any questions for you.
3.2. AREAS OF ASSESSMENT
Note that all the questions and scales referred to in this section are collected in a standardised assessment form starting on page 21.
Drug use history
Find out about all drugs the patients has used and how he or she has used them. A drug use history form is included in the standardised assessment form for this purpose (p.22). This form lists different drug types and for each drug asks:
How old were you when you first used this drug?
How long have you used this drug regularly?
Frequency of use and amount used over the past 3 months
Last episode of drug use
Route of administration
Have you ever overdosed?
Have you ever experienced withdrawal symptoms in the past?
Ask the patient these questions for each drug type listed. In addition, if the patient responds that they have injected a drug, ask about injecting behaviours (p. 23):
Have you ever used a needle or syringe after some one else has used it?
Do you have any infections or sores around where you inject?
Have you been tested for HIV, hepatitis C or hepatitis B?
Provide all patients who inject drugs with information about HIV transmission and prevention.
If the patient indicates they have previously experienced withdrawal symptoms, ask:
What symptoms did you experience?
What did you do or what medications did you take to relieve these symptoms?
Did you experience any serious complications such as seizures or hallucinations?
Do you have any concerns about your withdrawal?
Do you feel that you are in withdrawal now?
If the patient has concerns or is in withdrawal, do your best to alleviate this. Provide accurate information about what symptoms can be expected and how long they may last. If possible, provide medication to relieve symptoms.
Ask the patient if he or she has previously undergone treatment for their drug use. Find out what sort of treatment, and whether they found it helpful.
Assess whether the patient is drug dependent. This can be done using the Severity of Dependence Scale (SDS; p. 24). Ask the patient the SDS questions for the main drug or drugs the patient uses. If the patient equals or exceeds the shown cut-off score for a particular drug, it is likely that they are dependent on that drug. Note that the SDS is not used to assess dependence on inhalants. There are no reliable instruments for assessing inhalant dependence; rely on patient reports of previous withdrawals to guide decision-making around inhalant dependence.
Psychosocial history
It is also important to obtain an understanding of how the person's drug use has affected their daily life. You might say to the patient “thank you for co-operating with the assessment so far. Now, I'd like to ask you a little bit about how drugs have affected your life. Can you tell me about your family?”
When asking questions about a patient's family and friends, be sure that the patient understands that you are not asking the patient to tell you the names of other people who use drugs – you just want to understand how drug use has affected their life.
Ask the patient to describe their:
Family situation – do family members know about your drug use? Are they willing to be a supportive influence?
Other close relationships – do you have a girlfriend or boyfriend (remember that some patients may have same-sex partners)? Are you married? Has drug use affected your relationship with this person? Does he/she use drugs? Do you have children? Who is caring for your children? How many close friends do you have? Do many of your friends use drugs?
Employment situation – were you employed before you came to the closed setting? What sort of work have you done in the past? Do you want employment training to help you get a job after you leave the closed setting?
Medical history
REMINDER: DUTY OF CLOSED SETTINGS TO PROVIDE CARE
Closed settings have a duty to provide health care equivalent to that available in the community. Hence, if a patient discloses that they have a serious or chronic illness, it is the responsibility of the closed setting to provide treatment or care for that illness, including medication as appropriate.
A drug dependent patient's withdrawal can be complicated by medical illnesses. However, the patient may not understand why you want to know about their medical history. Introduce the medical history questions with a phrase such as “now, I'd like to ask you about any medical problems you may have had in the past, or have now. This is very important, as it will help us if you suddenly get sick or if you need medication.”
Ask the patient if they have any history of, or currently have:
Seizures or epilepsy
Diabetes
Heart disease
Liver disease
Viral hepatitis
Tuberculosis
Head injury
Physical or intellectual disability (note type of disability)
Allergies to any medications
Any prescribed or over-the-counter medications they are currently taking
Female patients should be asked if they are pregnant and offered the opportunity to take a pregnancy test.
Many people who use drugs have poor mental health. Ask the patient:
Have you ever been diagnosed with schizophrenia?
Have you ever been diagnosed with depression or bipolar disorder?
Have you ever been diagnosed with post-traumatic stress disorder?
Have you ever been diagnosed with any other mental health problem?
Have you ever been given medication for a mental illness?
Have you ever deliberately hurt yourself or tried to kill yourself? Do you feel like you may try to hurt or kill yourself?
Patients who have been taking medications for mental health problems should be permitted to continue these.2 Patients who disclose self-harming or suicidal intent should be referred to a psychiatrist or psychiatric nurse for further assessment and care. They may need to be taken from the closed setting and hospitalised.
Administer the Kessler-10 Psychological Distress Scale (K10; p. 27). This scale provides an indication of levels of psychological distress experienced by the patient. Patients who have been diagnosed with a mental illness, or who are experiencing moderate or severe psychological distress according to the K10, should be provided with specialised psychiatric or psychological care.
Ending the assessment
Completing an assessment can be a difficult thing for some patients. It may be the first time they have spoken to anyone about their drug use or other problems. At the end of the assessment, explain to the patient that you will now take some time to go through what you have written down, and will develop a treatment plan that you think is suitable for the patient.
If the patient is distressed, provide reassurance and ensure the patient is regularly supervised. In cases of severe distress, refer to specialist psychiatric or psychological care.
Standardised assessment form
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| Patient name | |
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| Date of birth | |
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| Patient record number | |
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| Date of admission | |
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| Assessment conducted by | |
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| Date of assessment | |
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DRUG USE HISTORY
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Drug:
(For each category list the specific name or type of drug used) | How old were you when you first used this drug? | How long have you used this drug regularly? | Drug use in the last 3 months: | Last time drug was used: | Route of administration | Have you ever overdosed? | Have you experienced withdrawal symptoms in the past? |
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| Frequency of use | Amount used each occasion | Time since last use | Amount last used | By mouth | Smoked | Injected | Other |
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| Alcohol | | | | | | | | | | | | |
| Heroin | | | | | | | | | | | | |
| Other opioids | | | | | | | | | | | | |
| Benzodiazepines | | | | | | | | | | | | |
| Methamphetamine/amphetamine | | | | | | | | | | | | |
| Cannabis | | | | | | | | | | | | |
| Ecstasy | | | | | | | | | | | | |
| Inhalants | | | | | | | | | | | | |
| Other | | | | | | | | | | | | |
| | | | | | | | | | | | |
| | | | | | | | If YES ask risk behaviour questions | | If YES ask risk behaviour questions |
Injecting behaviours
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| Yes/no | If yes, |
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| Do you have any sores or infections around your injecting sites? | | Arrange for medical examination and treatment |
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| Have you injected drugs using a needle that had already been used by someone else? | | Provide information about HIV transmission |
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| Have you ever been tested for HIV or hepatitis C? | | Can you tell me the results?3 |
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| Record test results, if provided: |
- 3
Although you may ask patients if they have been tested for HIV, you cannot force them to tell you their test result; it is up to the patient to decide whether to reveal this information
Withdrawal symptoms and previous treatments
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| What withdrawal symptoms did you experience? | |
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| What did you do, or what medications did you take, to relieve these symptoms? Did they work? | |
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| Did you experience any serious complications such as seizures or hallucinations? | |
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Do you have any concerns about your withdrawal?
(If yes, provide information about withdrawal and how it will be managed) | |
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Do you feel you are in withdrawal now?
(If yes, find out what symptoms and offer symptpomatic medication) | |
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| What treatments for drug dependence have you previously undertaken? Were they helpful? | |
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Severity of Dependence Scale
The following questions are about your drug use before coming to this centre.
In the last month, what was your primary drug, or the drug that you used the most often?
(When reading out the text below, replace “drug” with the type of drug the patient has nominated as his or her primary drug)
For each of the next five questions, please indicate the most appropriate response as it applied to your use of “drug”.
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| Never/almost never | Sometimes | Often | Always/nearly always |
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| 1. Did you think your use of “drug” was out of control? | 0 | 1 | 2 | 3 |
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| 2. Did the prospect of not using “drug” make you anxious or worried? | 0 | 1 | 2 | 3 |
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| 3. Did you worry about your use of “drug”? | 0 | 1 | 2 | 3 |
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| 4. Did you wish you could stop using “drug”? | 0 | 1 | 2 | 3 |
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| | | | |
| Not difficult | Quite difficult | Very difficult | Impossible |
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| 5. How difficult did you find it to stop or go without “drug”? | 0 | 1 | 2 | 3 |
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Add the scores for questions 1-5 to obtain the total SDS score for this drug:
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| Drug | SDS score indicating dependence |
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| Alcohol | 3 or more |
| Cannabis | 7 or more |
| Heroin, other opioids | 5 or more |
| Methamphetamine, amphetamine | 4 or more |
| Cocaine | 3 or more |
| Benzodiazepines | 6 or more |
Compare the total SDS score to the table below to assess dependence on this drug.
Psychosocial history
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| Can you tell me about your family? (Who are the members of your family? What is your relationship with them like? Does your family know about your drug use? Are they willing to support you after you are released?) | |
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| Can you tell me about any other significant relationships in your life?4 (Do you have a girlfriend/boyfriend/wife/husband? How has drug use affected your relationship? Does he/she use drugs? Do you have children? Who is caring for them? How many close friends do you have? Do they use drugs? How has drug use affected your relationships with your friends?) | |
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| Can you tell me about what work or study you did before you came here? (Were you employed? What skills do you have? Do you want employment training to help you get a job after you are released?) | |
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- 4
Emphasise to the patient that you are asking these questions to find out about how drug use has affected his or her life and relationships – you are not asking the patient to give you names of other drug users.
Medical history
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| PHYSICAL HEALTH |
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| Do you have any history of… | Details |
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| Seizures or epilepsy? | □ | |
| Diabetes? | □ | |
| Heart disease? | □ | |
| Liver disease? | □ | |
| Viral hepatitis? | □ | |
| Tuberculosis? | □ | |
| Head injury? | □ | |
| Physical or intellectual disability? | □ | |
| Allergies to any medication? | □ | |
| What medications are you currently taking? | |
| For female patients: Is there any possibility you may be pregnant? | |
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| MENTAL HEALTH |
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| Have you ever been diagnosed with… | Details |
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| Schizophrenia? | □ | |
| Depression or bipolar disorder? | □ | |
| Post-traumatic stress disorder? | □ | |
| Other mental health problems? | □ | |
| Have you ever deliberately hurt yourself or tried to kill yourself? | □ | |
| Do you feel like you may hurt yourself or want to kill yourself at the moment? | □ | |
Kessler-10 Psychological Distress Scale (K-10)
These questions are about how you have been feeling in the past 4 weeks. Please listen to each question and tell me how much it has applied to you over the past 4 weeks – none of the time, a little of the time, some of the time, most of the time, or all of the time.
(Read out response options after each question)
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| In the past 4 weeks, | None of the time | A little of the time | Some of the time | Most of the time | All of the time |
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| 1. How often did you feel worn out for no good reason? | 1 | 2 | 3 | 4 | 5 |
| 2. How often did you feel nervous? | 1 | 2 | 3 | 4 | 5 |
| 3. How often did you feel so nervous that nothing could calm you down? | 1 | 2 | 3 | 4 | 5 |
| 4. How often did you feel hopeless? | 1 | 2 | 3 | 4 | 5 |
| 5. How often did you feel restless or fidgety? | 1 | 2 | 3 | 4 | 5 |
| 6. How often did you feel so restless you could not sit still? | 1 | 2 | 3 | 4 | 5 |
| 7. How often did you feel depressed? | 1 | 2 | 3 | 4 | 5 |
| 8. How often did you feel that everything was an effort? | 1 | 2 | 3 | 4 | 5 |
| 9. How often did you feel so sad that nothing could cheer you up? | 1 | 2 | 3 | 4 | 5 |
| 10. How often did you feel worthless? | 1 | 2 | 3 | 4 | 5 |
Add the scores for questions 1-10 to obtain the total K10 score:
Compare the total score to the table below to determine level of psychological distress:
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| Score | Interpretation |
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| 10-19 | No/low psychological distress |
| 20-24 | Mild psychological distress |
| 25-29 | Moderate psychological distress |
| 30-50 | Severe psychological distress |
3.3. TREATMENT PLANNING USING THE STEPPED CARE APPROACH
Different people have different withdrawal management and treatment needs. Each patient in a closed setting should have a treatment plan: a document that sets out what treatment he or she will be offered while in the closed setting.
Developing a treatment plan involves reviewing the patient's assessment and consulting with the patient as necessary. The patient has the right to be involved in making decisions about what treatment he or she receives, and involving the patient can help to improve patient co-operation with treatment.
The treatment plan should be developed using the stepped care approach. Stepped care involves matching treatment to patients based on the least intensive intervention that is expected to be effective. Based on how the patient responds to the chosen intervention, the healthcare worker can increase (‘step up’) or reduce (‘step down’) the intensity of treatment. This approach optimises the use of resources by reducing unnecessarily intensive treatment.
Developing a treatment plan
A template for developing a treatment plan is provided on page 31. To develop a treatment plan, use the patient's assessment to answer the following questions:
Does the patient require withdrawal management?
Patients will only need withdrawal management if they are dependent on a drug. To determine if this is the case, check whether the patient's Severity of Dependence Scale score indicates dependence. Also check whether the patient reported previously or currently experiencing withdrawal symptoms. These are all signs that a patient may require withdrawal management.
If the patient is dependent on heroin or other opioids, discuss the option of methadone maintenance treatment (MMT) or other opioid substitution treatment (OST). Patients commencing MMT do not need to undergo withdrawal before starting treatment.
Patients who are not dependent on any drug will not need withdrawal management and can commence treatment immediately.
If withdrawal management is required, what drug/s is/are the patient withdrawing from?
Select the appropriate withdrawal management protocol from Part 4: Withdrawal Management. If a patient is withdrawing from a drug not discussed in these guidelines, seek assistance from colleagues or access other resources to guide withdrawal management.
What is the least intensive treatment that I expect to be effective for this patient?
Based on the patient's reported drug use, determine the least intensive treatment that you consider will have an impact on the patient. The interventions that are discussed in these guidelines are ranked by their intensity in .
Intensity of interventions for stepped care treatment planning.
Remember that not all people who use drugs need lengthy treatment; for some people, a brief education session may be all that is required. For others, a two-step treatment plan may be devised, with the patient completing withdrawal management and then stepping down in intensity to psychosocial interventions. See for some examples of appropriate treatment approaches for different patients.
Examples of stepped care treatment approaches.
What other patient concerns need to be addressed?
Patients may have other medical and psychological concerns that require attention, such as medication for other illnesses. Ensure that these needs are met.
Inform the patient about other opportunities in the closed setting, such as vocational training or performance groups. These activities complement the treatments described in these guidelines.
If the closed setting has the capacity to provide HIV tests, including pre- and post-test counselling, offer the patients the opportunity to take an HIV test. Testing should only be conducted voluntarily after informed consent has been obtained from the patient.
Treatment plan review: Stepping up or stepping down
Once a treatment plan has been commenced, it is important to regularly evaluate the patient's progress and determine if the interventions that were used have been useful to the patient. This provides a basis for either ‘stepping up’ - increasing the intensity of the intervention - or ‘stepping down’ - decreasing the intensity of the intervention.
If the patient has progressed well in treatment, then the intensity of treatment is reduced. Methods for reducing the intensity of treatment may include:
If the patient is not progressing in treatment, then the intensity of treatment may need to be increased. Methods for increasing the intensity of treatment may include:
Increasing the frequency of treatment sessions.
Introducing new treatment sessions e.g. moving from the brief intervention to the extended intervention.
Introducing new issues into treatment sessions e.g. discussing mental health as well as drug use.
It is important to note that if a person is being successfully treated with methadone maintenance treatment, they should remain on this treatment and be assisted to transfer to community-based methadone treatment when they leave the closed setting.
Treatment plan template
Does the patient require withdrawal management?
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| Yes | □ | No | □ |
| Justification: | □ Drug dependent | Justification: | □ Not drug dependent |
| □ Previous withdrawal symptoms | □ Opioid dependent and commencing methadone maintenance treatment |
| □ Current withdrawal symptoms | □ Other: |
| □ Other: |
Withdrawal management plan selected:
□ Opioid withdrawal management
□ Benzodiazepine withdrawal management
□ Stimulant withdrawal management
□ Alcohol withdrawal management
□ Inhalant withdrawal management
□ Cannabis withdrawal management
□ Other:
□ Not applicable; patient does not require withdrawal management
Treatment/s selected:
□Drug education
□Brief psychosocial intervention
□Extended psychosocial intervention
□Methadone maintenance treatment
□Other:
Other patient concerns and how they will be managed:
Date for treatment plan review:
