CEP Workshop Series 2013 Module 4: Assessment Workbook

Fraser Todd & Michelle Fowler 2013

This workshop is provided through the Mental Health Education Resource Centre and supported by the Canterbury District Health Board. It is one of a series of workshops designed to help practitioners and services improve their capability to work with people experiencing complicated and complex mental heath problems. The material presented in this workshop is drawn from Te Ariari o te Oranga (Todd 2010), though is updated here in several areas. Copyright is asserted by Fraser Todd over the content. It may be freely used with permission. The name Te Ariari o te Oranga means the dynamics of well -being. The name was coined by that staff ad students of Te Ngaru Learning Systems, was given to a series of bicultural training events on co-exiting and mental health and substance use problems (CEP) over the past decade, and given to the document Te Ariari o te Oranga: The Assessment and Management of Co-existing Mental Health and Substance Use Problems (Todd 2010) by Paraire Huata. As a term, it captures the practice and teaching of CEP in New Zealand where bicultural approaches are honoured.

Welcome to this Workshop

This workshop on Assessment of CEP is the third of six advanced workshops. The relevant section in Te Ariari o te Oranga is essential background reading and much of that content will not be repeated in the workshop.

The MHERC CEP Workshop Series

Workshop 1: 1a. Introduction to CEP for frontline staff 1b. Introduction to CEP for managers Workshop 2: Recovery and Wellbeing Workshop 3: Motivation and Engagement Workshop 4: Assessment Workshop 5: Management I Workshop 6: Management II Workshop 7: Integrated Care To attend workshops 2-7, it is expected that participants will have either attended module 1 OR completed a selfdirected learning package based on Workshop 1. It is essential that they are conversant with the generic principles that will be the focus of Workshop 1.

Workshop Overview
Screening and assessment processes The aims of a multi-dimensional/comprehensive assessment Key features of a comprehensive assessment Aetiological formulation Screening tools

Learning Intentions
Participants will be provided with the opportunity to: Understand the main types of assessment and screening tools which can be utilised Understand the aims of a multi-dimensional/comprehensive assessment in the treatment planning for people presenting with CEP Be able to utilise screening tools for assessment

 Understand aetiological formulation and how to apply this in practice

Te Whare o Tiki Assessment

In addition, we will aim to cover the engagement and motivation components of the CEP Skills Framework Te Whare o Tiki. Te Whare O Tiki has been produced by Matua Raki to provide guidance and direction for learning and practice development in CEP.
Assessment is the fifth domain of the skills set and includes the following skills at three levels of competence, foundation, capable and enhanced:

Te Whare o Tiki Assessment

In addition, we will aim to cover the engagement and motivation components of the CEP Skills Framework Te Whare o Tiki. Te Whare O Tiki has been produced by Matua Raki to provide guidance and direction for learning and practice development in CEP.
Assessment is the fifth domain of the skills set and includes the following skills at three levels of competence, foundation, capable and enhanced.

5. Assessment Screen all tangata whaiora presenting to mental health and addiction services for co=existing problems and ensure that a comprehensive assessment and problem formulation is carried out when co-existing problem are identified.

5.1

Screening for: a) b) c) Substance use disorders Mental health disorders Problem gambling

5.2 5.3 5.4

Brief Interventions Mental Health, substance use and gambling assessment DSM-IV/V and/or ICD-10 criteria Assessment of impact of substance use, gambling and mental health disorders on children,

family and whanau 5.5 5.6 5.7 Including COPMIA (Children of Parents with a Mental Illness and Addiction) Mental State Examination Risk Management Assessment (and synthesis) of relationships between substance use disorders, problem

gambling and other mental health disorders 5.8 5.9 Monitoring and testing of substances, including alcohol and medications Evaluation of stages of change in relation to problematic issues and the application of the

model to treatment planning.

Background Reading
Reading and knowledge to support this workshop can be found in the relevant chapters of Te Ariari o te Oranga. This workbook will include further information where there are updates to the content of Te Ariari.

Workshop Outline
Mihi and Introductions

Housekeeping Workshop overview Introductory Mindfulness Exercise Screening Exercise 2 Experience with Screening Tools Brief Assessment and Intervention Exercise 3 Practising a Brief Intervention Aetiological Formulation Exercise Formulation and the Case of Rachel Action Planning

Exercise 1: Mindfulness Introduction Instructions will be given in the workshop.

Levels of Assessment
Assessment can be thought of as occurring at different levels of intensity. 1. Screening Very brief, often self-reported questionnaires designed to identify if someone is likely to have a problem requiring further assessment. Designed for widespread use. 2. Brief Assessment A quick semi-structured series of questions aimed at identifying the level of a problem when it does exist (often detected with a positive screening). Milder problems may be dealt with through a brief intervention. More severe problems require a comprehensive assessment. 3. Comprehensive Assessment A more wide ranging assessment that screens for and assesses a wide range of problems from multiple domains. It my be efficient to consider two levels of comprehensive assessment, the first identifying diagnoses and problems that indicate straightforward and standard interventions, and when this does not work adequately a second level where deeper trans-diagnostic problems are identified and become an additional focus for treatment.

Similarly, treatment can follow the assessment process in a stepped care approach. Within Step 3 are two levels of intervention. The first involves the diagnosis of relevant problems and the application of an integrated treatment plan combining standard treatments for both AOD and mental health problems. For example someone with diagnoses of borderline personality disorder and alcohol use disorder might be referred to group DBT treatment included substance use components. In many cases this would be sufficient for a good outcome. But in many cases it would not and a more intensive individualized treatment plan based on the identification of key maintaining factors from the Aetiological formulation would be added.

Screening
The aim of screening is to apply a very brief process that can be widely used to identify people who are likely to have a particular problem. A positive screen should lead on to a more in-depth assessment. This is usually a brief assessment that is then followed by a brief intervention, though it may be obvious that a more comprehensive assessment is necessary. There is a wide range of tools available for screening. Many to some things very well, others not at all. Below are a number of screening tools that are thought to be most useful. Note that the AUDIT does what it does very well, but it only screens for alcohol use problems. The WHO-ASSIST is probably the only substance use screen that does things all services need. The Modified MINI Screen also covers a wide range of mental health problems very superficially. Given the number of different mental health problems that may present, more detailed screeners become too large and unwieldy to be useful. Ultimately services need to choose the screen that is most suitable for nature of the people they see in their services. It is also worth considering that a brief assessment that includes informal screening for a wide range of mental health

problems and that I carried out by well trained clinicians is often more efficient than the use of formal screening instruments.

Exercise 2: Screening On the following pages are several screening instruments: 1. The WHO-ASSIST 2. The Substances and Choices Scale (SACS) for adolescents 4. The AUDIT 3. The Modified MINI Screen for mental health 4. Eight Gambling Screen Chose several screening instruments that relate most to the needs of your workplace and complete them. Make sure you include the WHO-ASSIST and the SACS.

Discussion

Scales Included:
WHO-ASSIST Substances and Choices Scale (SACS) (for adolescents) The AUDIT (for alcohol) The Modified MINI-Screen (for mental health problems) The Eight Gambling Screen The Fagerstrom Test for Nicotine Dependence

A. WHO - ASSIST V3.0

INTERVIEWER ID COUNTRY CLINIC

PATIENT ID

DATE

INTRODUCTION (Please read to patient) Thank you for agreeing to take part in this brief interview about alcohol, tobacco products and other drugs. I am going to ask you some questions about your experience of using these substances across your lifetime and in the past three months. These substances can be smoked, swallowed, snorted, inhaled, injected or taken in the form of pills (show drug card). Some of the substances listed may be prescribed by a doctor (like amphetamines, sedatives, pain medications). For this interview, we will not record medications that are used as prescribed by your

doctor. However, if you have taken such medications for reasons other than prescription, or taken them more frequently or at higher doses than prescribed, please let me know. While we are also interested in knowing about your use of various illicit drugs, please be assured that information on such use will be treated as strictly confidential. NOTE: BEFORE ASKING QUESTIONS, GIVE ASSIST RESPONSE CARD TO PATIENT

Question 1 (if completing follow-up please cross check the patients answers with the answers given for Q1 at baseline. Any differences on this question should be queried) In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY) a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: No Yes

0 0 0 0 0 0 0 0 0 0

3 3 3 3 3 3 3 3 3 3

If "No" to all items, stop interview. Probe if all answers are negative: Not even when you were in school? If "Yes" to any of these items, ask Question 2 for each substance ever used.

Question 2 Monthly Once or Twice Weekly 4 4 4 4 4 4 4 4 4 4 Never In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, ETC)? a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: Daily or Almost Daily 6 6 6 6 6 6 6 6 6 6 Daily or Almost 6 6 6 6 6 6 6 6 6 6 Daily

0 0 0 0 0 0 0 0 0 0

2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3

If "Never" to all items in Question 2, skip to Question 6. If any substances in Question 2 were used in the previous three months, continue with Questions 3, 4 & 5 for each substance used.

Question 3 Weekly 5 5 5 5 5 5 5 5 5 5 Never During the past three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, ETC)? a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: Monthly 4 4 4 4 4 4 4 4 4 4 Once or Twice 3 3 3 3 3 3 3 3 3 3

0 0 0 0 0 0 0 0 0 0

Question 4 Monthly Once or Twice Weekly 6 6 6 6 6 6 6 6 6 6 Never During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems? a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: Daily or Almost Daily 7 7 7 7 7 7 7 7 7 7 Daily or Almost Daily 8 8 8 8 8 8 8 8 8

0 0 0 0 0 0 0 0 0 0

4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5

Question 5 Weekly 7 7 7 7 7 7 7 7 7 Never During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)? a. Tobacco products b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: 0 0 0 0 0 0 0 0 0 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 Monthly Once or Twice

Ask Questions 6 & 7 for all substances ever used (i.e. those endorsed in Question 1) Question 6 Yes, in the past 3 months No, Never Has a friend or relative or anyone else ever expressed concern about your use of (FIRST DRUG, SECOND DRUG, ETC.)? a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other specify: Yes, but not in the past 3 months 3 3 3 3 3 3 3 3 3 3 Yes, but not in the past 3 months 3 3 3 3 3 3 3 3 3 3

0 0 0 0 0 0 0 0 0 0

6 6 6 6 6 6 6 6 6 6

Question 7 Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC.)? Yes, in the past 3 months 6 6 6 6 6 6 6 6 6 6 No, Never 0 0 0 0 0 0 0 0 0 0

a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other specify:

Question 8 Yes, in the past 3 months No, Never Yes, but not in the past 3 months 1 treatment * 27+ 27+ 27+ 27+ 27+ 27+ 27+ 27+ 27+ 27+

Have you ever used any drug by injection? (NON-MEDICAL USE ONLY)

IMPORTANT NOTE: Patients who have injected drugs in the last 3 months should be asked about their pattern of injecting during this period, to determine their risk levels and the best course of intervention. PATTERN OF INJECTING Once weekly or less Fewer than 3 days in a row More than once per week 3 or more days in a row HOW TO CALCULATE A SPECIFIC SUBSTANCE INVOLVEMENT SCORE. For each substance (labeled a. to j.) add up the scores received for questions 2 through 7 inclusive. Do not include the results from either Q1 or Q8 in this score. For example, a score for cannabis would be calculated as: Q2c + Q3c + Q4c + Q5c + Q6c + Q7c Note that Q5 for tobacco is not coded, and is calculated as: Q2a + Q3a + Q4a + Q6a + Q7a or or INTERVENTION GUIDELINES Brief Intervention including risks associated with injecting card

Further assessment and more intensive treatment*

THE TYPE OF INTERVENTION IS DETERMINED

BY THE PATIENTS SPECIFIC SUBSTANCE INVOLVEMENT SCORE

Record specific substance score a. tobacco b. alcohol c. cannabis d. cocaine e. amphetamine f. inhalants g. sedatives h. hallucinogens i. opioids j. other drugs

no intervention

receive brief intervention

more intensive

0 - 3 0 - 10 0 - 3 0 - 3 0 - 3 0 - 3 0 - 3 0 - 3 0 - 3 0 - 3

4 - 26 11 - 26 4 - 26 4 - 26 4 - 26 4 - 26 4 - 26 4 - 26 4 - 26 4 - 26

NOTE: *FURTHER

ASSESSMENT AND MORE INTENSIVE TREATMENT

may be provided by the health professional(s)

within your primary care setting, or, by a specialist drug and alcohol treatment service when available.

B. WHO ASSIST V3.0 RESPONSE CARD FOR PATIENTS

Response Card - substances a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify:

Response Card (ASSIST Questions 2 5) Never: not used in the last 3 months Once or twice: 1 to 2 times in the last 3 months. Monthly: 1 to 3 times in one month. Weekly: 1 to 4 times per week. Daily or almost daily: 5 to 7 days per week.

Response Card (ASSIST Questions 6 to 8) No, Never Yes, but not in the past 3 months Yes, in the past 3 months

C. ALCOHOL, SMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST (WHO ASSIST V3.0) FEEDBACK REPORT CARD FOR PATIENTS
Name Test Date

Specific Substance Involvement Scores Substance a. Tobacco products Score 0-3 4-26 27+ 0-10 11-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ Risk Level Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High

b. Alcoholic Beverages

c. Cannabis

d. Cocaine

e. Amphetamine type stimulants

f. Inhalants

g. Sedatives or Sleeping Pills

h. Hallucinogens

i. Opioids

j. Other - specify

Low: Moderate: High:

What do your scores mean? You are at low risk of health and other problems from your current pattern of use. You are at risk of health and other problems from your current pattern of substance use. You are at high risk of experiencing severe problems (health, social, financial, legal, relationship) as a result of your current pattern of use and are likely to be dependent Are you concerned about your substance use?

a. tobacco

Your risk of experiencing these harms is: Regular tobacco smoking is associated with: Premature aging, wrinkling of the skin Respiratory infections and asthma High blood pressure, diabetes Respiratory infections, allergies and asthma in children of smokers

Low

Moderate High (tick one)

Miscarriage, premature labour and low birth weight babies for pregnant women Kidney disease Chronic obstructive airways disease Heart disease, stroke, vascular disease Cancers b. alcohol Your risk of experiencing these harms is: Low Moderate (tick one) High

Regular excessive alcohol use is associated with: Hangovers, aggressive and violent behaviour, a c c i d e n t s and injury Reduced sexual performance, p r e m a t u r e ageing Digestive problems, ulcers, inflammation of the pancreas, high blood pressure Anxiety and depression, relationship difficulties, financial and work problems Difficulty remembering things and solving problems Deformities and brain damage in babies of pregnant women Stroke, p e r m a n e n t brain injury, m usc l e and nerve damage Liver disease, p a n c r e a s disease Cancers, s u i c i d e c. cannabis Your risk of experiencing these harms is: Regular use of cannabis is associated with: Problems with attention and motivation Anxiety, paranoia, panic, depression Decreased memory and problem solving ability High blood pressure Asthma, bronchitis Psychosis in those with a personal or family history of schizophrenia Heart disease and chronic obstructive airways disease Cancers Low Moderate (tick one) High

d. Cocaine

Your risk of experiencing these harms is:. Regular use of cocaine is associated with: Difficulty sleeping, h e a r t racing, headaches, w e i g h t loss Numbness, tingling, c l a m m y skin, skin scratching or picking Accidents and injury, fi nanci al problems Irrational thoughts Mood swings - anxiety, depression, mania Aggression and paranoia Intense craving, stress from the lifestyle Psychosis after repeated use of high doses Sudden death from heart problems

Low

Moderate (tick one)

High

e. amphetamine type stimulants

Your risk of experiencing these harms is:.

Low

Moderate (tick one)

High

Regular use of amphetamine type stimulants is associated with: Difficulty sleeping, l o s s of appetite and weight loss, dehydration jaw clenching, headaches, m u s c l e pain Mood swings anxiety, d e p r e s s i o n , agitation, mania, panic, p a r a n o i a Tremors, i r r e g u l a r heartbeat, shortness of breath Aggressive and violent behaviour Psychosis after repeated use of high doses Permanent damage to brain cells Liver damage, b r a i n haemorrhage, sudden death (ecstasy) in rare situations

f. inhalants

Your risk of experiencing these harms is:..

Low

Moderate (tick one)

High

Regular use of inhalants is associated with: Dizziness and hallucinations, drowsiness, disorientation, blurred vision Flu like symptoms, s i n u s i t i s , nosebleeds Indigestion, stomach ulcers Accidents and injury Memory loss, confusion, depression, aggression Coordination difficulties, s l o w e d reactions, hypoxia Delirium, seizures, c o m a , o r g a n damage (heart, lungs, l i v e r , kidneys) Death from heart failure

g. sedatives

Your risk of experiencing these harms is: Regular use of sedatives is associated with: Drowsiness, dizziness and confusion Difficulty concentrating and remembering things Nausea, headaches, unsteady gait Sleeping problems Anxiety and depression Tolerance and dependence after a short period of use. Severe withdrawal symptoms

Low

Moderate (tick one)

High

Overdose and death if used with alcohol, opioids or other depressant drugs. h. hallucinogens Your risk of experiencing these harms is:.. Low Moderate (tick one) High

Regular use of hallucinogens is associated with: Hallucinations (pleasant or unpleasant) visual, auditory, tactile, olfactory Difficulty sleeping Nausea and vomiting Increased heart rate and blood pressure Mood swings Anxiety, panic, p a r a n o i a Flash-backs Increase the effects of mental illnesses such as schizophrenia i. opioids Your risk of experiencing these harms is: Regular use of opioids is associated with: Itching, nausea and vomiting Drowsiness Constipation, tooth decay Difficulty concentrating and remembering things Reduced sexual desire and sexual performance Relationship difficulties Financial and work problems, violations of law Tolerance and dependence, withdrawal symptoms Overdose and death from respiratory failure Low Moderate (tick one) High

D. RISKS OF INJECTING CARD INFORMATION FOR PATIENTS

Using substances by injection increases the risk of harm from substance use. This harm can come from: The substance If you inject any drug you are more likely to become dependent. If you inject amphetamines or cocaine you are more likely to experience psychosis. If you inject heroin or other sedatives you are more likely to overdose. The injecting behaviour If you inject you may damage your skin and veins and get infections. You may cause scars, bruises, swelling, abscesses and ulcers. Your veins might collapse. If you inject into the neck you can cause a stroke. Sharing of injecting equipment If you share injecting equipment (needles & syringes, spoons, filters, etc.) you are more likely to spread blood borne virus infections like Hepatitis B, Hepatitis C and HIV. It is safer not to inject If you do inject: always use clean equipment (e.g., needles & syringes, spoons, filters, etc.) always use a new needle and syringe dont share equipment with other people clean the preparation area clean your hands clean the injecting site use a different injecting site each time inject slowly put your used needle and syringe in a hard container and dispose of it safely If you use stimulant drugs like amphetamines or cocaine the following tips will help you reduce your risk of psychosis. avoid injecting and smoking avoid using on a daily basis If you use depressant drugs like heroin the following tips will help you reduce your risk of overdose. avoid using other drugs, especially sedatives or alcohol, on the same day use a small amount and always have a trial taste of a new batch have someone with you when you are using avoid injecting in places where no-one can get to you if you do overdose know the telephone numbers of the ambulance service

E. TRANSLATION AND ADAPTATION TO LOCAL LANGUAGES AND CULTURE: A RESOURCE FOR CLINICIANS AND RESEARCHERS
The ASSIST instrument, instructions, drug cards, response scales and resource manuals may need to be translated into local languages for use in particular countries or regions. Translation from English should be as direct as possible to maintain the integrity of the tools and documents. However, in some cultural settings and linguistic groups, aspects of the ASSIST and its companion documents may not be able to be translated literally and there may be socio-cultural factors that will need to be taken into account in addition to semantic meaning. In particular, substance names may require adaptation to conform to local conditions, and it is also worth noting that the definition of a standard drink may vary from country to country. Translation should be undertaken by a bi-lingual translator, preferably a health professional with experience in interviewing. For the ASSIST instrument itself, a bi-lingual expert panel to ensure that the instrument is not ambiguous should review translations. Back translation into English should then be carried out by another independent translator whose main language is English to ensure that no meaning has been lost in the translation. This strict translation procedure is critical for the ASSIST instrument to ensure that comparable information is obtained wherever the ASSIST is used across the world. Translation of this manual and companion documents may also be undertaken if required. These do not need to undergo the full procedure described above, but should include an expert bi-lingual panel. Before attempting to translate the ASSIST and related documents into other languages, interested individuals should consult with the WHO about the procedures to be followed and the availability of other translations. Write to the Department of Mental Health and Substance Dependence, World Health Organisation, 1211 Gen

21

SUBSTANCES AND CHOICES SCALE

Name. Date of birth No..

The SACS is only to be used by health professionals working with young people who are engaged in a treatment agency.
The questions in part A) and B) are about your use of alcohol and drugs over the last month. prescribed medicine. Please answer every question as best you can, even if you are not certain. This does not include tobacco or Tick only one box on each row.

A) H o w of t e n d i d y o u us e eac h o f t h e
fo l l o w i n g in t h e las t m o n t h ?
1. Alcoholic drinks (e.g. beer, wine, spirits, premixes) 2. Cannabis (e.g. weed, marijuana) 3. Ecstasy and other party pills (e.g. E, Methadrone, BZP) 4. Hallucinogens (e.g. LSD, acid, mushrooms, ketamine) 5. Inhalants (e.g. glue, petrol, solvents, paint, nitrous) 6. Amphetamines (e.g. speed, P, ice, whiz) 7. Sedatives (e.g. sleeping pills, benzos, downers, valium) 8. Synthetic cannabinoids (smokable herbal highs ) 9. Opiates (e.g. heroin, morphine, methadone, codeine) 10. Cocaine (e.g. coke, crack, blow) 11. Other drug. Write name here 12. Other drug. Write name here

Di dn t u s e

Onc e a we e k or l ess

Mo r e t h a n once a we ek

Mo s t d a y s or m or e

Not Tr u e

Som ew hat Tr u e

Ce r t ai nl y Tr u e

B ) M a r k o n e b o x ( o n e a c h r o w ) , o n t h e b as i s o f h o w t h in g s h a v e b e e n f o r y o u o ver t h e l a st m o n th .
1. I took alcohol or drugs when I was alone.

2. Ive thought I might be hooked or addicted to alcohol or drugs.

Onc e a we e k or l ess

Mo r e t h a n once a w eek

Connect the boxes with a straight line and turn the page up this way to see your SACS Difficulties Mountain Range like here. Is your progress smooth or rocky?

YOUR S ACS DI F F I CUL I T I E S M O U N T A I N R A N G E

3. Most of my free time has been spent getting hold of, taking, or recovering from alcohol or drugs. 4. Ive wanted to cut down on the amount of alcohol and drugs that I am using. 5. My alcohol and drug use has stopped me getting important things done. 6. My alcohol or drug use has led to arguments with the people I live with (family, flatmates or caregivers etc.). 7. Ive had unsafe sex or an unwanted sexual experience when taking alcohol or drugs. 8. My performance or attendance at school (or at work) has been affected by my alcohol or drug use. 9. I did things that could have got me into serious trouble (stealing, vandalism, violence etc) when using alcohol or drugs. 10. I've driven a car while under the influence of alcohol or drugs (or have been driven by someone under the influence).

SACS di f f i cul t i e s sca l e

C ) F i n a l l y, h o w o f t e n h a v e y o u u s e d t o b a c c o (e . g . c i g a r e t t e s , c i g a r s ) in t he l a s t m o n t h?

Ne v e r

Mo s t d a y s or m or e

22

Date completed..... ..

Clinician

Notes . . .
SACSclinical2011 substancesandchoicesscale2011

23

Alcohol Use DIsorders Identification Test (AUDIT)

For the following 10 questions, please circle the answer that is most correct for you 1. How often do you have a drink containing alcohol? never 2. monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week

How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more

3.

How often do you have six or more drinks on one occasion? never less than monthly monthly weekly daily or almost daily

4.

How often during the last year have you found that you were not able to stop drinking once you had started? never less than monthly monthly weekly daily or almost daily

5.

How often during the last year have you failed to do what was normally expected from you because of drinking? never less than monthly monthly weekly daily or almost daily

6.

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? never less than monthly monthly weekly daily or almost daily

7.

How often during the last year have you had a feeling of guilt or remorse after drinking? never less than monthly monthly weekly daily or almost daily

8.

How often during the last year have you been unable to remember what happened the night before because you had been drinking? never less than monthly monthly weekly daily or almost daily

9.

Have you or someone else been injured as a result of your drinking? no yes, but not in the last year yes, during the last year

10

Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down? no yes, but not in the last year yes, during the last year

Modified Mini
24

Screen (MMS)
Client Name: Weeks since admission Todays Date OASAS ID Interviewer Supervisor Initials (Optional)

SECTION A

1. Have you been consistently depressed or down, most of the day, nearly every day, for the past 2 weeks?

YES

NO

2. In the past 2 weeks, have you been less interested in most things or less able to enjoy the things you used to enjoy most of the time?

YES

NO

3. Have you felt sad, low or depressed most of the time for the last two years?

YES

NO

4. In the past month, did you think that you would be better off dead or wish you were dead?

YES

NO

5. Have you ever had a period of time when you were feeling up, hyper or so full of energy or full of yourself that you got into trouble or that other people thought you were not your usual self? (Do not consider times when you were intoxicated on drugs or alcohol.)

YES

NO

6. Have you ever been so irritable, grouchy or annoyed for several days, that you had arguments, verbal or physical fights, or shouted at people outside your family? Have you or others noticed that you have been more irritable or overreacted, compared to other people, even when you thought you were right to act this way?

YES

NO

PLEASE TOTAL THE NUMBER OF YES RESPONSES TO QUESTIONS 1-6

25

SECTION B

7. Note this question is in 2 parts. a. Have you had one or more occasions when you felt intensely anxious, frightened, uncomfortable or uneasy even when most people would not feel that way? YES NO b. If yes, did these intense feelings get to be their worst within 10 minutes? YES NO Interviewer: If the answer to BOTH a and b is YES, code the question YES. If the answer to either or both a and b is NO, code the question NO. 8. Do you feel anxious or uneasy in places or situations where you might have the paniclike symptoms we just spoke about? Or do you feel anxious or uneasy in situations where help might not be available or escape might be difficult? Examples include: Being in a crowd Standing in a line Being alone away from home or alone at home Crossing a bridge Traveling in a bus, train or car 9. Have you worried excessively or been anxious about several things over the past 6 months? Interviewer: If NO to question 9, answer NO to question 10 and proceed to question 11.

YES

NO

YES

NO

YES

NO

10. Are these worries present most days?

YES

NO

11. In the past month, were you afraid or embarrassed when others were watching you, or when you were the focus of attention? Were you afraid of being humiliated? Examples include: Speaking in public Eating in public or with others Writing while someone watches Being in social situations YES NO

12. In the past month, have you been bothered by thoughts, impulses, or images that you couldnt get rid of that were unwanted, distasteful, inappropriate, intrusive or distressing? Examples include: Were you afraid that you would act on some impulse that would be really shocking? Did you worry a lot about being dirty, contaminated or having germs? Did you worry a lot about contaminating others, or that you would harm someone even though you didnt want to? Did you have any fears or superstitions that you would be responsible for things going wrong? Were you obsessed with sexual thoughts, images or impulses? Did you hoard or collect lots of things? Did you have religious practice obsessions?

YES

NO

26

SECTION B (CONTINUED)

13. In the past month, did you do something repeatedly without being able to resist doing it? Examples include: Washing or cleaning excessively Counting or checking things over and over Repeating, collecting, or arranging things Other superstitious rituals 14. Have you ever experienced or witnessed or had to deal with an extremely traumatic event that included actual or threatened death or serious injury to you or someone else? Examples Include: Serious accidents Sexual or physical assault Terrorist attack Being held hostage Kidnapping Fire Discovering a body Sudden death of someone close to you War Natural disaster YES NO

YES

NO

15. Have you re-experienced the awful event in a distressing way in the past month? Examples include: Dreams Intense recollections Flashbacks Physical reactions

YES

NO

PLEASE TOTAL THE NUMBER OF YES RESPONSES TO QUESTIONS 7-15

27

SECTION C

16. Have you ever believed that people were spying on you, or that someone was plotting against you, or trying to hurt you?

YES

NO

17. Have you ever believed that someone was reading your mind or could hear your thoughts, or that you could actually read someones mind or hear what another person was thinking?

YES

NO

18. Have you ever believed that someone or some force outside of yourself put thoughts in your mind that were not your own, or made you act in a way that was not your usual self? Or, have you ever felt that you were possessed?

YES

NO

19. Have you ever believed that you were being sent special messages through the TV, radio, or newspaper? Did you believe that someone you did not personally know was particularly interested in you?

YES

NO

20. Have your relatives or friends ever considered any of your beliefs strange or unusual?

YES

NO

21. Have you ever heard things other people couldnt hear, such as voices?

YES

NO

22. Have you ever had visions when you were awake or have you ever seen things other people couldnt see?

YES

NO

PLEASE TOTAL THE NUMBER OF YES RESPONSES TO QUESTIONS 16-22

28

SCORING THE SCREEN

NUMBER OF YES RESPONSES FROM SECTION A

NUMBER OF YES RESPONSES FROM SECTION B

NUMBER OF YES RESPONSES FROM SECTION C

TOTAL NUMBER OF YES RESPONSES FROM SECTIONS A, B, AND C Score > 10, assessment needed Score > 6 & < 9, assessment need should be determined by treatment team Score < 5, no action necessary unless determined by treatment team

YES RESPONSE TO QUESTION #4 If score = 1, assessment is needed

YES RESPONSES TO QUESTIONS #14 AND #15 If score = 2, assessment is needed

SCORE INDICATED NEED FOR AN ASSESSMENT? (CIRCLE) IF NO, DID TREATMENT TEAM DETERMINE THAT AN ASSESSMENT WAS NEEDED? (CIRCLE)

YES

NO

YES NO

29

Eight Gambling Screen

Early Intervention Gambling Health Test 1. Sometimes Ive felt depressed or anxious after a session of gambling yes, thats true 2. no, I havent

Sometimes Ive felt guilty about the way I gamble yes, thats so no, that isnt so

3.

When I think about it, gambling has sometimes caused me problems yes, thats so no, that isnt so

4.

Sometimes Ive found it better not to tell others, especially my family, about the amount of time or money I spend gambling yes, thats true no, I havent

5.

I often find that when I stop gambling Ive run out of money yes, thats so no, that isnt so

6.

Often I get the urge to return to gambling to win back losses from a past session yes, thats so no, that isnt so

7.

Yes, I have received criticism about my gambling in the past yes, thats true no, I havent

8.

Yes, I have tried to win money to pay debts yes, thats true no, I havent

Scoring Guide
If you answer YES to 4 or more questions gambling may be causing you problems in your life.

EIGHT Screen (Early Intervention Gambling Health Test) Developed by Dr Sean Sullivan Abacus Counselling & Training Services Ltd www.acts.co.nz

30

Fagerstrom Test for Nicotine Dependence

1. How soon after you wake up do you smoke your first cigarette? After 60 minutes (0) 31-60 minutes (1) 6-30 minutes (2) Within 5 minutes (3)

2. Do you find it difficult to refrain from smoking in places where it is forbidden? No (0) Yes (1)

3. Which cigarette would you hate most to give up? The first in the morning (1) Any other (0)

4. How many cigarettes per day do you smoke? 10 or fewer (0) 11-20 (1) 21-30 (2) 31 or more (3)

5. Do you smoke more frequently during the first hours after awakening than during the rest of the day? No (0) Yes (1)

6. Do you smoke if you are so ill that you are in bed most of the day? No (0) Yes (1)

How did you do? If your score is below four points, your addiction to nicotine is not all that severe and you should be able to stop smoking fairly easily. If you score above seven points your nicotine dependence is high.

31

Brief Assessment and Intervention

Brief Alcohol and Drug Assessment
There are a considerable number of different brief assessments described. A brief assessment of substance use problems is designed to take 5-10 minutes followed by a similar length brief intervention, and to be undertaken in a primary care setting. However, if it is also very useful in a specialist setting where other mental health problems have already been assessed, or where there are few other problems. A brief assessment is indicated when a screening is positive or when someone presents with mild alcohol problems. It may then lead on to a more comprehensive assessment, or to a brief intervention. The nature of a brief assessment for alcohol use problems differs from that for other substances given that there are clear guidelines or levels for the safe use of alcohol (determined by ALAC, now part of the Health Promotion Agency) while there are not for other substances. For alcohol, the brief assessment and intervention outlined below has been used and is supported by research evidence. For other substances it is probably preferable to use the FRAMES brief intervention approach based on the WHO-ASSIST. Either the WHO-ASSIST or a brief assessment may precede the FRAMES brief intervention. Other CBT brief interventions may be considerably longer than this. For example, brief CBT interventions for cannabis dependence involve four 1-hour sessions,

Brief Assessment
A brief assessment of alcohol and drug use can be undertaken in 5-10 minutes. It would usually occur after either a brief screening was positive or the person presented with an alcohol and drug problem. Indications for referral for a comprehensive assessment include: Moderate to severe dependence Serious risk issues The presence of serious comorbid mental health problems that are not treated or adequately addressed Failure of previous brief interventions Multiple problematic substance use Indications for a brief intervention include Problematic use or mild dependence The absence of indications for a comprehensive assessment (above)

Structure of a Brief Assessment

32

History 1. 2. 3. Demographics Current use (quantity/frequency in the past six months) Beginnings (age at first intoxication, regular use, first alcohol-related problem) Pattern (overview of pattern including the main problems and the six month period of heaviest use of alcohol) Dependence (applying the DSMIV criteria to the heaviest six month period of heaviest use to establish a lifetime diagnosis or not) Other drug use (brief history of other drug use) Treatment (brief A&D treatment history) Psychiatric (brief psychiatric history) Medical (current significant medical conditions)

4. 5.

6. 7. 8. 9.

10. Family (family history of A&D) 11. Miscellaneous (is there anything else you would like to tell me a this stage, not necessarily related to your drinking?) Examination 1. 2. General Appearance (checking obvious mental and physical disorder) Readiness to Change (establishing stage of change pre-contemplation, contemplation, determination, action)

33

DSMIV Alcohol Dependence criteria (heaviest 6 months) and suggested questions

1.
(adapted from Zimmerman 1994):

Alcohol taken in larger amounts or for longer periods of time than intended
When you drank, did you often drink more than you had planned? Did you often drink for more time than you had planned?

2.

Persistent desire/unsuccessful attempts to cut down/control alcohol use

Did you frequently think about cutting down or stopping drinking? At times did you try to cut down or stop but couldnt?

3.

A great deal of time spent in activities necessary to get alcohol, drink alcohol or recover from its effects
Did you spend a lot of time doing things or planning ways to get alcohol? How much time did you spend drinking? Did you spend a lot of time recovering from drinking, for example with hangovers?

4.

Important social, occupational or recreational activities given up or reduced because of alcohol use
less time

Did you spend so much of your time drinking so that you missed work a lot, or spent with family or friends, or gave up hobbies or interests?

5.

Continued use despite knowledge of having a persistent or recurrent medical or psychological problem likely to have been caused or exacerbated by alcohol
Did drinking cause physical or psychological problems? IF YES: Like what? Did you keep drinking despite this?

6.

Tolerance
a. Over time, did you drink a lot more to get high or get the same effect as before? IF YES how much more? b. Did you develop a tolerance to alcohol so that the same amount as before did not have the same

effect?

7.

Withdrawal symptoms or relief use

a. Did you experience any or the symptoms of withdrawal when you tried to stop alcohol or cut down your use? b. Did you often drink or take anything else to stop withdrawal symptoms or prevent them coming

Brief Alcohol and Drug Intervention

34

FRAMES Intervention
A brief assessment and intervention usually combines brief advice with a motivational interviewing approach and has a sound evidence base for mild to moderate problems. In fact evidence suggests it may be just as effective for mild problems as a more comprehensive assessment and interventions. For most drugs, the FRAMES approach is advised. An alcohol brief intervention may use this approach also, but there is a well-researched structure (below) that differs slightly from the FRAMES approach and uses clear guidelines for the low risk use of alcohol. Similar guidelines do not exit for other substances.

Structure of the Brief Intervention

Ask permission to discuss the issues and ask permission to discuss the screening score (e.g. WHOASSIST score) or the cause for concern. Feedback Give personally relevant feedback; level of substance use, level of harm or risk associated with this. If based on the ASSIST screening, can use the ASSIST feedback report card Responsibility Acknowledge that the client is responsible for their own behaviour and decisions Are you interested to know how you scored on the questionnaire/? How concerned are you by your score/by how much you use? What you do with this information is up to you Consider asking the client to weigh the good and the bad things about their use of the substance Advice Provide clear and objective advice regarding how to reduce harms associated with continued use. The best way you can reduce your risk is by cutting down or stopping X Set a goal. Menu Build a menu of options or strategies for reducing or stopping the substance. First elicit possible strategies from the client, then offer more if needed. Empathy use the motivational principles of supporting self-efficacy by expressing your confidence that the client can achieve their goal. Summarize Summarize the clients concerns and reflect clients statements with emphasis on less good things Finally, it is essential to negotiate a follow-up date to check progress.

Specific Brief Intervention for Alcohol

35

Brief Intervention for Alcohol

Step 1: Summarise assessment findings Drinking pattern (quantity and frequency) Drinking-related problems Symptoms of dependence Presence of contra-indications Positive family history

Step 2: Brief Tutorial Outline ALAC drinking guidelines Educate about what is a standard drink Relate these guidelines to their own drinking, by calculating number of standard drinks consumed per session/week, and presence of contra-indications (driving, liver damage etc) Give the information that about 20-30% of New Zealanders misuse alcohol Invite their comment

Step 3: Giving Advice Advise of risk of continued heavy drinking (individualise) Advise drinking within the ALAC drinking guidelines which may include abstinence In an engaging interactive way, suggest several drinking behaviour changes if patient wishes to change

Step 4: Negotiating Change Negotiate what a new drinking goal and/or change in drinking behaviour will be Negotiate how this reduction will be brought about Negotiate when a review of this goal (normally less than three months) can occur

Health Promotion Agency/ALAC Guidelines for Low Risk Drinking

1. Reduce your long-term health risks by drinking no more than: 2 standard drinks a day for women and no more than 10 standard drinks a week 3 standard drinks a day for men and no more than 15 standard drinks a week 2. Have at least two non-drinking days every week.

36

3. Reduce your risk of injury on a single occasion of drinking by drinking no more than: 4 standard drinks for women on any single occasion 5 standard drinks for men on any single occasion People should drink less than these guidelines if: Pregnant Thin Young or old positive family history of alcohol problems a history of other drug use problems driving, operating other heavy machinery, swimming medical or psychiatric problems

Menu of Strategies to Reduce Alcohol Consumption

Dont do rounds Eat a meal before drinking Drink water before starting to drink alcohol Alternate alcoholic and non-alcoholic drinks Pace yourself with the slowest drinker Put the glass down between drinks

FRAMES Intervention for Multiple Substance Use

In this instance, the approach is similar to that when dealing with a single problematic substance except that you will go though the FRAMES process with each substance. This will, of course require a longer session.

FRAMES Intervention for High Risk and Intravenous Drug Use

The FRAMES can be used for high risk and intravenous drug use but the aim in these circumstances is to refer for a comprehensive assessment. Of note, if the client chooses to continue using IV but at lower levels, advice should be given on safe using practices such as not sharing needles.

Exercise 3: Brief Intervention

1. Get into pairs. 2. Choose one of the scenarios below. 3. One person role-plays the client while the other undertakes a brief intervention in about 5-7 minutes

37

4. Change roles, with the other in the pair undertaking a brief intervention in about 5-7 minutes

SCENARIO 1: Anne has completed the audit and has scored 14. On further brief screening you find out that:

Anne is a 35-year-old mother who is currently being treated for anxiety. She reports a pattern of drinking two glasses of wine Mon-Thurs night and consuming a bottle of wine on Friday to Saturday night. She is concerned that recently she has started having memory lapses and her anxiety levels have increased following a heavier drinking session. She reported having an argument with her partner, who has expressed concern over her drinking and contacted the service.

Over the next 5-7 minutes conduct an appropriate brief intervention with Anne.

SCENARIO 2:

Stephen is a 19 year old, whom you are conducting a brief screening with. Stephen recently took an overdose of 20 panadol following a heavy drinking session. During the assessment Stephen reports he has been drinking heavily on occasions. On further screening:

Stephen reports drinking Friday and Saturday nights a 12 pack of 8 % RTD Bourbon and cokes

38

 He has recently been charged with DUI, which caused him to lose his job He reports drinking to relax in social situations He reports that recently he has been getting into fights whilst intoxicated and had to attend A&E for stitches to his face. His parents and girlfriend has expressed concern about his drinking due to his behaviour whilst intoxicated and are concerned for his safety There is a family history of heavy binge drinking He does not meet criteria for dependence

Over the next 5-7 minutes please conduct an appropriate brief intervention with Stephen

Strategy for the Assessment of Mental Health Problems

There are no standardized brief assessments widely used for other mental health problems. In practice the usual approach is to ask a screening question to pick up any problems in a range of areas, then follow up in response to a positive screen the questions that one would normally ask in an assessment around those problems It is worth noting that it is essential when considering the relationship between mental health and substance use to get a longitudinal history of mental health symptoms and the presence and intensity of these problems over time since their onset. Simply asking about current symptoms is a common failing in assessments and results in difficulty considering the interplay between mental health and substance use. 1. For problems where there is a clear date of onset: (For example, substance use, PTSD, depression or anxiety triggered by a particular event) Begin with the start of the symptoms e.g. first drink, the triggering event. Fully explore the development of symptoms over time until their maximum intensity. Assess DSMIV criteria at the point of maximal intensity or heaviest use Identify periods of low intensity or absent symptoms Assess current dysfunction, DSMIV symptoms

2. For problems where there is no easily identified onset: (For example, psychosis with a very gradual onset, depression with gradual onset over a period of a few years) Begin with current symptoms over, say, the past month. Assess DSMIV criteria and levels of dysfunction over this period Ask if there has ever been periods like this in the past. Identify when symptoms first occurred Identify the course over time periods of waxing and waning, periods without symptoms

39

The use of a timeline to capture multiple problems over time is highly recommended (below)

Comprehensive Assessment
Overview of The Comprehensive Assessment
See Te Ariari o te Oranga section on Assessment

Assessing the Relationship Between Mental Health and Substance Use

It is important to note that levels of substance use below that meeting criteria for a diagnosis may impact on mental health problems. It is essential to consider quantity and frequency of use as well as dependence symptoms, and to complete a substance use history regardless of whether a diagnosis is present or not. There are four main strategies that give a picture of the relationship between mental health and substance use: 1. The likely relationship between the substance/s and the mental heath problems Is the substance known to impact on the mental health problem? 2. Timing of onset For both substance use and the mental health problem. Note that many problems have a slow and insidious onset with mild or prodromal symptoms present for a long time before the disorder reveals itself fully. These symptoms may impact on substance use and its onset. For example, schizophrenia, bipolar disorder and major depression often have prodromes that precede the onset of substance use even if the core symptoms do not emerge until well after. In addition, vulnerability factors such as shyness and withdrawal that may be associated with later anxiety disorders may precede and influence the onset of substance use. It is important to note that the onset of substance use before the onset of clear mental health disorder does not necessarily mean that the substance use has caused the mental health problem 3. Family history Most mental health and addiction problems have a genetic component and therefore run in families. The presence of a family history of a particular disorder suggests it is likely that the disorder is primary in the client. 4. Symptoms during abstinence The persistence of mental heath symptoms during periods of abstinence from a substance indicates that the mental heath problem is primary (the substance use may also be primary). Usually a period of two to three months of abstinence needs to be identified to be clear about the relationship. For cannabis and amphetamines, a period of three to five months may be necessary

The Issue of Primary v Secondary

It is often stated that when there are both substance use and mental health problems present, both areas should be treated as primary. There is some sense in this; it is often true, and when substance use problems may seem secondary to mental health problems, they frequently take a life of their own making their initial secondary status (i.e. casually secondary to mental health problems) somewhat irrelevant. However, in some circumstances the primary/secondary distinction is useful. For example: Alcohol use and depression o A syndrome identical to major depressive episode is common with heavy alcohol use. In the majority of these cases, the depression is secondary to the pharmacological effects of alcohol and is resolved with a period of abstinence.

40

Cannabis use or stimulant use and psychosis o Brief psychotic episodes can occur directly attributable to the use of cannabis or stimulants, and especially when both are used in combination. These may be time limited and ameliorate with a period of abstinence. Mental health problems that cause secondary substance use problems. In these cases, aggressive treatment of the mental health problem is usually necessary for any improvement in substance use to be sustained, and once the mental health problem is stabilised and treated, the substance use is often much easier to treat. Such disorders include: o Bipolar disorder o Social phobia o PTSD o

Functional Analysis of Substance Use

(See Mueser, Kim. T. Noordsy, Douglas, L. Drake, Robert, E. Fox, L. Integrated Treatment for Dual Diagnosis: A Guide to Effective Practice Pg 65-71. The Guildford Press. New York 2003) A functional analysis is used to identify the role particular behaviours play in a persons life. Usually for people with CEP, it is the role substance use plays. On the face of it, the functional analysis appears similar to a decisional balance (good things and not so good things) but differs in that that the behaviours in question are looked at from the perspective of what the behaviour maximizes and what the behaviour minimizes. The behaviour may serve a function in terms of enhancing positive features or diminishing negative features. For example substance use may enhance socialization or pleasurable experiences and may reduce anxiety in a range of situations. Thus substance use serves a purpose for the person and identifying these specific purposes is essential in understanding the maintenance of the behaviour. The functional analysis is most effective when it leads to interventions that help find other, ore adaptive or useful ways of achieving a goal. The Payoff Matrix is a useful tool to help develop a functional analysis.

The Payoff Matrix

Using Substances Advantages (as experienced by the client) Not Using Substances

Disadvantages (as experienced by the client)

Examples of advantages and disadvantages

41

Using Substances Advantages (as experienced by the client) Pleasurable feelings Reduced negative feelings Social acceptance Alleviation of craving and withdrawals Something positive to look forward to

Not Using Substances Reversal of negative effects Achieve personal goals Enhanced quality of life Look to past periods of abstinence

Disadvantages (as experienced by the client) Relapses Financial problems Worsening mental health Impaired parenting Conflict in relationships Violence Suicidal thinking Physical health (e.g. infection) (Mueser et al 2003) What are the costs of giving up? Peer pressure Loss of peer relationships and social isolation Loss of pleasure Re-emergence of mental health symptoms Sense of failure Medication side effect Boredom Craving & Withdrawals

Timelines
These are particularly useful for identifying the relationship between substance use, mental health problems and various life events. We have discussed the timeline for the case of Rachel in a previous workshop. Below is a diagram of the Rachels timeline to refresh your memory and exemplify the usefulness of the timeline.

42

The Aetiological (Causal) Formulation

The Aetiological or causal formulation is part of the opinion and is the point around which the comprehensive assessment revolves. It is a set of linked, evidence-informed hypotheses that seeks to explain the causes of the persons current situation through a narrative. In doing so, it identifies underlying variables and serves to integrate different perspectives and domains. It is not a description of the presentation. The aetiological formulation looks at causes, takes a longitudinal perspective and is better suited to identifying underlying or latent causes that underpin several of person's problems. These underlying factors may be potent points of intervention. A good formulation serves many purposes. As mentioned, it is a useful way of identifying common underlying factors that cause and maintain problems. But it is also a very important point of integration, bringing together a wide range of different factors. As such, it can be help people make sense of a complex situation.

43

Further, it helps make meaning for tangata whaiora of their situation and can be healing in its own right.

The steps to doing an Aetiological formulation are: 1. Identify key explanatory factors from the history 2. Draw a 4x4 grid 3. Label the grid 4. Enter factors into each box of the grid 5. Produce four paragraphs to make a narrative pattern over time (chronic, acute, intermittent, self-sustaining etc) predisposing and precipitating factors maintaining factors protecting factors or strengths

44

The 4x4 grid is simply a tool to help clinicians organise their thinking and to prompt them to consider factors they might not normally. There is no right or wrong way to fill in the grid and no right or wrong place to put factors. It is helpful when deciding on a factor to enter, to ask how that factor will influence treatment does it suggest a specific intervention or does it tie together a number of other factors to enhance the explanatory power of the formulation. A key function of the grid is to force clinicians to think beyond the usual paradigms they use. With experience, a lot of our decision-making rests on pattern recognition. While this is highly effective in many situations, the weakness of pattern-recognition is that we only recognize the patterns we know. When filling the grid out, it is therefore important to concentrate on those areas we are less familiar with and which we may skip over.

45

46

Exercise 4: Rachels Aetiological Formulation

47

1. Get into small groups 2. Appoint a scribe and someone who will feed back to the class 3. You will be given one aspect of the 4x4 grid to complete for the case scenario of Rachel (repeated below for your reference) 4. Take 20 minutes to complete the aspect of the grid you have been assigned. Below the case of Rachel is a list of evidence-based factors commonly involved in the aetiology of CEP. You may refer to this list as a prompt for factors to consider. We will develop the grid as a class group.

Case Scenario - Rachel

Rachel is a 30-year-old European mother of a 5 year-old daughter who was referred to your service via the local Emergency Department after having taken an overdose of 15 Paracetamol tablets the previous night. Rachel stated that the overdose had been an impulsive action after drinking a bottle of wine and having an argument with her partner about finances. She stated that she was not trying to kill herself or that she was at risk of future overdose as she was very embarrassed at the outcome. She was reluctant to attend the appointment with your service, but did so under pressure from her partner who threatened to leave her unless she did something about her drinking and her moodiness. History of Presenting Problems Rachel described her mood as low but believed that this was normal for her. At times her mood is worse than usual for a few weeks with persistent sadness, lack of energy and motivation and diminished pleasure from things she usually enjoys. This occurs once every three months on average. At these times she finds life a struggle and has thoughts that she would be better off dead but has never actually developed the intent to kill herself. Problems with low mood have occurred off and on since she experienced a sexual assault (rape) at a party while severely intoxicated at the age of 18 years. Since then she has experienced frequent intrusive memories and ruminations related to the rape which has impacted on her intimate relationships, and experiences hyper-arousal much of the time though it is worse when socializing in larger groups. She denies any other significant mental health problems. Alcohol and Drug History Rachel started drinking alcohol with friends around the age of 14 years but having seen her fathers drinking did not drink regularly or to intoxication until after the sexual assault at age18 years. She

48

started drinking to intoxication most weekend nights when socialising, and by the age of 20 years was drinking half to three quarters of a bottle of wine most evenings as well. Her alcohol use decreased when, at age 22 years she entered a relationship with the father of her daughter, and over the next few years she would drink occasionally when socializing but would have periods of several months at time without using alcohol. Her partner left her when she became pregnant and decided to keep the child. She stopped drinking when she became pregnant at aged 25 years and did not consume alcohol again until her daughter was a year old and she entered a new relationship with her current partner who also drinks heavily. For the past three years she has consumed a bottle of wine each night during the week, and up to three on Friday and Saturday nights if socializing. She acknowledges tolerance to alcohol and has tried to cut her drinking down in the past on several occasions without success. She also acknowledges that she gets argumentative with her partner when intoxicated on alcohol but denies other problems, and finds that it actually helps her to be calm in most situations. She has used cannabis on a daily basis since her mid teens and experiences craving, irritability and significant generalized anxiety when she goes without it for more than a few days, but find it helps her mood. Other than during her pregnancy, she has not had any significant periods of abstinence from cannabis. She has not used any other substances apart from tobacco, which she started smoking at 14. She currently smokes 50gms of tobacco a week and would like to stop, as it is very expensive. Other Relevant History Family History: Youngest of three siblings with an older sister and the eldest a brother. Her father died in a motor vehicle accident when Rachel was 22 years old. Father alcohol dependence. Paternal Grandfather alcohol dependence Brother convictions for assault and possession of cannabis, heavy cannabis user Mother social phobia, less problematic the last few years

Medical History: Nil of note No current medications Personal History: Rachel had a normal pregnancy, birth and early developmental milestones. She was an outgoing and happy toddler, over adventurous and exploratory. She attended six different primary schools due to her fathers frequent change in employment. At primary school she struggled academically with mathematics and reading but was otherwise intelligent, but frequently got into trouble for disobedience and being easily distracted. She was noted to have a short temper and be intolerant of discipline, talking back to teachers. She was sexually abused between on one occasion at the age of 5 by a friend of her fathers, and though she did not tell anyone, her older sister told their other she disliked him and their mother made sure he did not have access to the children. She was frequently truant from secondary school and noted to be irritable and argumentative when she did attend. Upon leaving school she worked in a range of waitressing, bar and sales jobs until becoming pregnant. Over the past two years she has taken several tertiary papers in social work and hopes to get a job in the future in community support. Her current relationship tends to involve frequent arguments though not violence. She has one or two friends whom she has know for ten years, but few other contacts she would consider more than acquaintances. Over the past 5 years she has had increasing contact with her mother, revolving around her daughter. Her siblings have lived in the United Kingdom for the last 7 or 8 years; she talks to her sister on skype once every few weeks, but has limited contact with her brother.

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Rachel 4x4 Grid

50

Vulnerability (Predisposing) Biological

Triggers (Precipitating)

Maintaining (Perpetuating)

Strengths (Protecting)

Psychological

Social

Spiritual

Rachel Formulation - Four Paragraphs

1. Pattern

51

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------2. Predisposing and Precipitating ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3. Perpetuating ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------52

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------4. Protecting ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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Menu of Some Factors for the 4x4 Grid

Developmental Transitions
e.g. Eriksons Stages Birth 1 year 10 months 4 years 3-5 years 5-10 years Adolescence Young Adulthood 1st Adulthood (18-30) 2nd Adulthood (30-45) Maturity (65+) trust v mistrust autonomy v shame and self doubt initiative v guilt industry v inferiority ego identity v role confusion intimacy v isolation generativity v stagnation or self-absorption career, marriage, parenthood midlife transition ego integrity v despair

Biological Factors
Genes In Utero effects alcohol and drug exposure, infection, trauma Birth hypoxia and trauma Infection Temperament novelty seeking, harm avoidance, Predisposition to psychiatric and medical illnesses Appearance Head Injury Stress, HPA axis, cortisol Substance use IQ Motor activation hyper-arousal, agitation and activation Pain Sleep issues Effortful control v Impulsivity - Impulsivity 1. response initiation 2. response inhibition 3. consequence insensitivity - Negative urgency also appears to be one way of conceptualizing one of the dimensions of impulsivity

Psychological Factors
Temperament and personality Temperament and Character (novelty seeking, reward dependence, harm avoidance, persistence, selfdirectedness, cooperativeness, self-transcendence Neuroticism Extraversion High Anxiety Emotion dysregulation Negative emotionality Situational stressors Impulsivity response initiation, response inhibition, consequence insensitivity Negative urgency Effortful control Rumination Overgeneralised autobiographical memory Loss and bereavement Unresolved grief Positive and negative reinforcement Motivation

54

Cognitive maps and schema Core beliefs - underlying assumptions automatic thoughts Thinking errors Over generalizations Personalization All or nothing thinking Emotional reasoning Mind reading Perfectionism Overgeneralised autobiographical memory the tendency to remember general rather than specific historical events (?avoidance), associated with abuse in childhood and appears to be a vulnerability factor for depression and a maintaining factor for PTSD Coping Resources (optimism, self-efficacy, self mastery, social skills) Processes approach or avoidance Specific strategies Skills Deficits Coping skills Problems solving skills Social skills Assertiveness Emotion regulation Anger management Parenting skills Dysfunctional self-talk Immature sense of self Unconscious dynamics Positive psychology Positive experiences engaging (flow) and meaningful experiences Positive thinking and optimism Character strengths and values Interests, abilities and accomplishments Positive relationships Enabling institutions

Social Factors
Marital relationship Family Parents Control and limit setting Under or overprotection Abuse; emotional, physical, sexual Intergenerational transmission; rules, customs, rituals, beliefs Dysfunctional communication Family roles Hierarchies Boundaries Individuation Enmeshment Emotional reactivity Disengagement Triangulation and scape-goating Social role Social networks

55

Community Support Violence Poverty Stigma Work environment Environment Basic needs e.g. housing, clothing, food, transport, living spaces Relevant income levels and discrepancies

Spiritual Factors
Spiritual crisis, guilt, intolerance of others Self-transcendence Ecological worldview Search for meaning, purpose and fulfillment Acceptance of suffering Hope Altruism Connection with the sacred Experiences inner peace, wholeness, creativity and flow, mystical experiences, boundaries of the self Beliefs connectedness, meaning, calling, life after death, divine purpose, Activities prayer, meditation, communing with nature, nourishing the soul, creative spiritual expression (art, reading, writing etc)

Cultural Considerations
Identity Acculturation Values Transgressions of sacred rules and spaces (Tapu) Curses and makutu

Action Plan
1. Before the next workshop, undertake a screening for substance use problems on a client, using the WHO-ASSIST. Follow with a brief intervention if appropriate.

2. Before the next workshop, chose a current client and attempt an Aetiological formulation.

56

Appendices and Resources

1. 2. 3. 4. 5. 6. 7. 8. The WHO-ASSIST Substance and Choices Scale (SACS) The Audit The Modified MINI-Screen The Eight Gambling Screen The Fagerstrom Test for Nicotine Dependence The Payoff Matrix Template Some Models of relevant conditions and trans-diagnostic factors

57

A. WHO - ASSIST V3.0

INTERVIEWER ID COUNTRY CLINIC

PATIENT ID

DATE

INTRODUCTION (Please read to patient ) Thank you for agreeing to take part in this brief interview about alcohol, tobacco products and other drugs. I am going to ask you some questions about your experience of using these substances across your lifetime and in the past three months. These substances can be smoked, swallowed, snorted, inhaled, injected or taken in the form of pills (show drug card). Some of the substances listed may be prescribed by a doctor (like amphetamines, sedatives, pain medications). For this interview, we will not record medications that are used as prescribed by your doctor. However, if you have taken such medications for reasons other than prescription, or taken them more frequently or at higher doses than prescribed, please let me know. While we are also interested in knowing about your use of various illicit drugs, please be assured that information on such use will be treated as strictly confidential. NOTE: BEFORE ASKING QUESTIONS, GIVE ASSIST RESPONSE CARD TO PATIENT

Question 1 (if completing follow-up please cross check the patients answers with the answers given for Q1 at baseline. Any differences on this question should be queried) In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY) a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: No Yes

0 0 0 0 0 0 0 0 0 0

3 3 3 3 3 3 3 3 3 3

If "No" to all items, stop interview. Probe if all answers are negative: Not even when you were in school? If "Yes" to any of these items, ask Question 2 for each substance ever used.

58

Question 2 Monthly Once or Twice Weekly 4 4 4 4 4 4 4 4 4 4 Never In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, ETC)? a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: Daily or Almost Daily 6 6 6 6 6 6 6 6 6 6 Daily or Almost 6 6 6 6 6 6 6 6 6 6 Daily

0 0 0 0 0 0 0 0 0 0

2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3

If "Never" to all items in Question 2, skip to Question 6. If any substances in Question 2 were used in the previous three months, continue with Questions 3, 4 & 5 for each substance used.

Question 3 Weekly 5 5 5 5 5 5 5 5 5 5 Never During the past three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, ETC)? a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: Monthly 4 4 4 4 4 4 4 4 4 4 Once or Twice 3 3 3 3 3 3 3 3 3 3

0 0 0 0 0 0 0 0 0 0

59

Question 4 Monthly Once or Twice Weekly 6 6 6 6 6 6 6 6 6 6 Never During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems? a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: Daily or Almost Daily 7 7 7 7 7 7 7 7 7 7 Daily or Almost Daily 8 8 8 8 8 8 8 8 8

0 0 0 0 0 0 0 0 0 0

4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5

Question 5 Weekly 7 7 7 7 7 7 7 7 7 Never During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)? a. Tobacco products b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify: 0 0 0 0 0 0 0 0 0 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 Monthly Once or Twice

60

Ask Questions 6 & 7 for all substances ever used (i.e. those endorsed in Question 1) Question 6 Yes, in the past 3 months No, Never Has a friend or relative or anyone else ever expressed concern about your use of (FIRST DRUG, SECOND DRUG, ETC.)? a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other specify: Yes, but not in the past 3 months 3 3 3 3 3 3 3 3 3 3 Yes, but not in the past 3 months 3 3 3 3 3 3 3 3 3 3

0 0 0 0 0 0 0 0 0 0

6 6 6 6 6 6 6 6 6 6

Question 7 Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC.)? Yes, in the past 3 months 6 6 6 6 6 6 6 6 6 6 No, Never 0 0 0 0 0 0 0 0 0 0

a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other specify:

61

Question 8 Yes, in the past 3 months No, Never Yes, but not in the past 3 months 1 treatment * 27+ 27+ 27+ 27+ 27+ 27+ 27+ 27+ 27+ 27+

Have you ever used any drug by injection? (NON-MEDICAL USE ONLY)

IMPORTANT NOTE: Patients who have injected drugs in the last 3 months should be asked about their pattern of injecting during this period, to determine their risk levels and the best course of intervention. PATTERN OF INJECTING Once weekly or less Fewer than 3 days in a row More than once per week 3 or more days in a row HOW TO CALCULATE A SPECIFIC SUBSTANCE INVOLVEMENT SCORE. For each substance (labelled a. to j.) add up the scores received for questions 2 through 7 inclusive. Do not include the results from either Q1 or Q8 in this score. For example, a score for cannabis would be calculated as: Q2c + Q3c + Q4c + Q5c + Q6c + Q7c Note that Q5 for tobacco is not coded, and is calculated as: Q2a + Q3a + Q4a + Q6a + Q7a or or INTERVENTION GUIDELINES Brief Intervention including risks associated with injecting card

Further assessment and more intensive treatment*

THE TYPE OF INTERVENTION IS DETERMINED

BY THE PATIENTS SPECIFIC SUBSTANCE INVOLVEMENT SCORE

Record specific substance score a. tobacco b. alcohol c. cannabis d. cocaine e. amphetamine f. inhalants g. sedatives h. hallucinogens i. opioids j. other drugs

no intervention

receive brief intervention

more intensive

0 - 3 0 - 10 0 - 3 0 - 3 0 - 3 0 - 3 0 - 3 0 - 3 0 - 3 0 - 3

4 - 26 11 - 26 4 - 26 4 - 26 4 - 26 4 - 26 4 - 26 4 - 26 4 - 26 4 - 26

NOTE: *FURTHER

ASSESSMENT AND MORE INTENSIVE TREATMENT

may be provided by the health professional(s)

within your primary care setting, or, by a specialist drug and alcohol treatment service when available.

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B. WHO ASSIST V3.0 RESPONSE CARD FOR PATIENTS

Response Card - substances a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, spirits, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) i. Opioids (heroin, morphine, methadone, codeine, etc.) j. Other - specify:

Response Card (ASSIST Questions 2 5) Never: not used in the last 3 months Once or twice: 1 to 2 times in the last 3 months. Monthly: 1 to 3 times in one month. Weekly: 1 to 4 times per week. Daily or almost daily: 5 to 7 days per week.

Response Card (ASSIST Questions 6 to 8) No, Never Yes, but not in the past 3 months Yes, in the past 3 months

63

C. ALCOHOL, SMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST (WHO ASSIST V3.0) FEEDBACK REPORT CARD FOR PATIENTS
Name Test Date

Specific Substance Involvement Scores Substance a. Tobacco products Score 0-3 4-26 27+ 0-10 11-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ 0-3 4-26 27+ Risk Level Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High Low Moderate High

b. Alcoholic Beverages

c. Cannabis

d. Cocaine

e. Amphetamine type stimulants

f. Inhalants

g. Sedatives or Sleeping Pills

h. Hallucinogens

i. Opioids

j. Other - specify

Low: Moderate: High:

What do your scores mean? You are at low risk of health and other problems from your current pattern of use. You are at risk of health and other problems from your current pattern of substance use. You are at high risk of experiencing severe problems (health, social, financial, legal, relationship) as a result of your current pattern of use and are likely to be dependent Are you concerned about your substance use?

64

a. tobacco

Your risk of experiencing these harms is: Regular tobacco smoking is associated with: Premature aging, wrinkling of the skin Respiratory infections and asthma High blood pressure, diabetes Respiratory infections, allergies and asthma in children of smokers

Low

Moderate High (tick one)

Miscarriage, premature labour and low birth weight babies for pregnant women Kidney disease Chronic obstructive airways disease Heart disease, stroke, vascular disease Cancers b. alcohol Your risk of experiencing these harms is: Low Moderate (tick one) High

Regular excessive alcohol use is associated with: Hangovers, aggressive and violent behaviour, accidents and injury Reduced sexual performance, premature ageing Digestive problems, ulcers, inflammation of the pancreas, high blood pressure Anxiety and depression, relationship difficulties, financial and work problems Difficulty remembering things and solving problems Deformities and brain damage in babies of pregnant women Stroke, permanent brain injury, muscle and nerve damage Liver disease, pancreas disease Cancers, suicide c. cannabis Your risk of experiencing these harms is: Regular use of cannabis is associated with: Problems with attention and motivation Anxiety, paranoia, panic, depression Decreased memory and problem solving ability High blood pressure Asthma, bronchitis Psychosis in those with a personal or family history of schizophrenia Heart disease and chronic obstructive airways disease Cancers Low Moderate (tick one) High

65

d. cocaine

Your risk of experiencing these harms is:. Regular use of cocaine is associated with: Difficulty sleeping, heart racing, headaches, weight loss Numbness, tingling, clammy skin, skin scratching or picking Accidents and injury, financial problems Irrational thoughts Mood swings - anxiety, depression, mania Aggression and paranoia Intense craving, stress from the lifestyle Psychosis after repeated use of high doses Sudden death from heart problems

Low

Moderate (tick one)

High

e. amphetamine type stimulants

Your risk of experiencing these harms is:.

Low

Moderate (tick one)

High

Regular use of amphetamine type stimulants is associated with: Difficulty sleeping, loss of appetite and weight loss, dehydration jaw clenching, headaches, muscle pain Mood swings anxiety, depression, agitation, mania, panic, paranoia Tremors, irregular heartbeat, shortness of breath Aggressive and violent behaviour Psychosis after repeated use of high doses Permanent damage to brain cells Liver damage, brain haemorrhage, sudden death (ecstasy) in rare situations

f. inhalants

Your risk of experiencing these harms is:..

Low

Moderate (tick one)

High

Regular use of inhalants is associated with: Dizziness and hallucinations, drowsiness, disorientation, blurred vision Flu like symptoms, sinusitis, nosebleeds Indigestion, stomach ulcers Accidents and injury Memory loss, confusion, depression, aggression Coordination difficulties, slowed reactions, hypoxia Delirium, seizures, coma, organ damage (heart, lungs, liver, kidneys) Death from heart failure

66

g. sedatives

Your risk of experiencing these harms is: Regular use of sedatives is associated with: Drowsiness, dizziness and confusion Difficulty concentrating and remembering things Nausea, headaches, unsteady gait Sleeping problems Anxiety and depression Tolerance and dependence after a short period of use. Severe withdrawal symptoms

Low

Moderate (tick one)

High

Overdose and death if used with alcohol, opioids or other depressant drugs. h. hallucinogens Your risk of experiencing these harms is:.. Low Moderate (tick one) High

Regular use of hallucinogens is associated with: Hallucinations (pleasant or unpleasant) visual, auditory, tactile, olfactory Difficulty sleeping Nausea and vomiting Increased heart rate and blood pressure Mood swings Anxiety, panic, paranoia Flash-backs Increase the effects of mental illnesses such as schizophrenia i. opioids Your risk of experiencing these harms is: Regular use of opioids is associated with: Itching, nausea and vomiting Drowsiness Constipation, tooth decay Difficulty concentrating and remembering things Reduced sexual desire and sexual performance Relationship difficulties Financial and work problems, violations of law Tolerance and dependence, withdrawal symptoms Overdose and death from respiratory failure Low Moderate (tick one) High

67

D. RISKS OF INJECTING CARD INFORMATION FOR PATIENTS

Using substances by injection increases the risk of harm from substance use. This harm can come from: The substance If you inject any drug you are more likely to become dependent. If you inject amphetamines or cocaine you are more likely to experience psychosis. If you inject heroin or other sedatives you are more likely to overdose. The injecting behaviour If you inject you may damage your skin and veins and get infections. You may cause scars, bruises, swelling, abscesses and ulcers. Your veins might collapse. If you inject into the neck you can cause a stroke. Sharing of injecting equipment If you share injecting equipment (needles & syringes, spoons, filters, etc.) you are more likely to spread blood borne virus infections like Hepatitis B, Hepatitis C and HIV. It is safer not to inject If you do inject: always use clean equipment (e.g., needles & syringes, spoons, filters, etc.) always use a new needle and syringe dont share equipment with other people clean the preparation area clean your hands clean the injecting site use a different injecting site each time inject slowly put your used needle and syringe in a hard container and dispose of it safely If you use stimulant drugs like amphetamines or cocaine the following tips will help you reduce your risk of psychosis. avoid injecting and smoking avoid using on a daily basis If you use depressant drugs like heroin the following tips will help you reduce your risk of overdose. avoid using other drugs, especially sedatives or alcohol, on the same day use a small amount and always have a trial taste of a new batch have someone with you when you are using avoid injecting in places where no-one can get to you if you do overdose know the telephone numbers of the ambulance service

68

E. TRANSLATION AND ADAPTATION TO LOCAL LANGUAGES AND CULTURE: A RESOURCE FOR CLINICIANS AND RESEARCHERS
The ASSIST instrument, instructions, drug cards, response scales and resource manuals may need to be translated into local languages for use in particular countries or regions. Translation from English should be as direct as possible to maintain the integrity of the tools and documents. However, in some cultural settings and linguistic groups, aspects of the ASSIST and its companion documents may not be able to be translated literally and there may be socio-cultural factors that will need to be taken into account in addition to semantic meaning. In particular, substance names may require adaptation to conform to local conditions, and it is also worth noting that the definition of a standard drink may vary from country to country. Translation should be undertaken by a bi-lingual translator, preferably a health professional with experience in interviewing. For the ASSIST instrument itself, translations should be reviewed by a bi-lingual expert panel to ensure that the instrument is not ambiguous. Back translation into English should then be carried out by another independent translator whose main language is English to ensure that no meaning has been lost in the translation. This strict translation procedure is critical for the ASSIST instrument to ensure that comparable information is obtained wherever the ASSIST is used across the world. Translation of this manual and companion documents may also be undertaken if required. These do not need to undergo the full procedure described above, but should include an expert bi-lingual panel. Before attempting to translate the ASSIST and related documents into other languages, interested individuals should consult with the WHO about the procedures to be followed and the availability of other translations. Write to the Department of Mental Health and Substance Dependence, World Health Organisation, 1211 Gen

69

SUBSTANCES AND CHOICES SCALE

Name. Date of birth No..

The SACS is only to be used by health professionals working with young people who are engaged in a treatment agency.
The questions in part A) and B) are about your use of alcohol and drugs over the last month. prescribed medicine. Please answer every question as best you can, even if you are not certain. This does not include tobacco or Tick only one box on each row.

A) H o w of t e n d i d y o u us e eac h o f t h e
fo l l o w i n g in t h e las t m o n t h ?
1. Alcoholic drinks (e.g. beer, wine, spirits, premixes) 2. Cannabis (e.g. weed, marijuana) 3. Ecstasy and other party pills (e.g. E, Methadrone, BZP) 4. Hallucinogens (e.g. LSD, acid, mushrooms, ketamine) 5. Inhalants (e.g. glue, petrol, solvents, paint, nitrous) 6. Amphetamines (e.g. speed, P, ice, whiz) 7. Sedatives (e.g. sleeping pills, benzos, downers, valium) 8. Synthetic cannabinoids (smokable herbal highs ) 9. Opiates (e.g. heroin, morphine, methadone, codeine) 10. Cocaine (e.g. coke, crack, blow) 11. Other drug. Write name here 12. Other drug. Write name here

Di dn t u s e

Onc e a we e k or l ess

Mo r e t h a n once a we ek

Mo s t d a y s or m or e

Not Tr u e

Som ew hat Tr u e

Ce r t ai nl y Tr u e

B ) M a r k o n e b o x ( o n e a c h r o w ) , o n t h e b as i s o f h o w t h in g s h a v e b e e n f o r y o u o ver t h e l a st m o n th .
1. I took alcohol or drugs when I was alone.

2. Ive thought I might be hooked or addicted to alcohol or drugs.

Onc e a we e k or l ess

Mo r e t h a n once a w eek

Connect the boxes with a straight line and turn the page up this way to see your SACS Difficulties Mountain Range like here. Is your progress smooth or rocky?

YOUR S ACS DI F F I CUL I T I E S M O U N T A I N R A N G E

3. Most of my free time has been spent getting hold of, taking, or recovering from alcohol or drugs. 4. Ive wanted to cut down on the amount of alcohol and drugs that I am using. 5. My alcohol and drug use has stopped me getting important things done. 6. My alcohol or drug use has led to arguments with the people I live with (family, flatmates or caregivers etc.). 7. Ive had unsafe sex or an unwanted sexual experience when taking alcohol or drugs. 8. My performance or attendance at school (or at work) has been affected by my alcohol or drug use. 9. I did things that could have got me into serious trouble (stealing, vandalism, violence etc) when using alcohol or drugs. 10. I've driven a car while under the influence of alcohol or drugs (or have been driven by someone under the influence).

SACS di f f i cul t i e s sca l e

C ) F i n a l l y, h o w o f t e n h a v e y o u u s e d t o b a c c o (e . g . c i g a r e t t e s , c i g a r s ) in t he l a s t m o n t h?

Ne v e r

Mo s t d a y s or m or e

70

Date completed..... ..

Clinician

Notes . . .
SACSclinical2011 substancesandchoicesscale2011

71

Alcohol Use DIsorders Identification Test (AUDIT)

For the following 10 questions, please circle the answer that is most correct for you 10. How often do you have a drink containing alcohol? never 11. monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week

How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more

12.

How often do you have six or more drinks on one occasion? never less than monthly monthly weekly daily or almost daily

13.

How often during the last year have you found that you were not able to stop drinking once you had started? never less than monthly monthly weekly daily or almost daily

14.

How often during the last year have you failed to do what was normally expected from you because of drinking? never less than monthly monthly weekly daily or almost daily

15.

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? never less than monthly monthly weekly daily or almost daily

16.

How often during the last year have you had a feeling of guilt or remorse after drinking? never less than monthly monthly weekly daily or almost daily

17.

How often during the last year have you been unable to remember what happened the night before because you had been drinking? never less than monthly monthly weekly daily or almost daily

18.

Have you or someone else been injured as a result of your drinking? no yes, but not in the last year yes, during the last year

11

Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down? no yes, but not in the last year yes, during the last year

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73

Modified Mini Screen (MMS)

Client Name: Weeks since admission Todays Date OASAS ID Interviewer Supervisor Initials (Optional)

SECTION A

1. Have you been consistently depressed or down, most of the day, nearly every day, for the past 2 weeks?

YES

NO

2. In the past 2 weeks, have you been less interested in most things or less able to enjoy the things you used to enjoy most of the time?

YES

NO

3. Have you felt sad, low or depressed most of the time for the last two years?

YES

NO

4. In the past month, did you think that you would be better off dead or wish you were dead?

YES

NO

5. Have you ever had a period of time when you were feeling up, hyper or so full of energy or full of yourself that you got into trouble or that other people thought you were not your usual self? (Do not consider times when you were intoxicated on drugs or alcohol.)

YES

NO

6. Have you ever been so irritable, grouchy or annoyed for several days, that you had arguments, verbal or physical fights, or shouted at people outside your family? Have you or others noticed that you have been more irritable or overreacted, compared to other people, even when you thought you were right to act this way?

YES

NO

PLEASE TOTAL THE NUMBER OF YES RESPONSES TO QUESTIONS 1-6

74

SECTION B

7. Note this question is in 2 parts. a. Have you had one or more occasions when you felt intensely anxious, frightened, uncomfortable or uneasy even when most people would not feel that way? YES NO b. If yes, did these intense feelings get to be their worst within 10 minutes? YES NO Interviewer: If the answer to BOTH a and b is YES, code the question YES. If the answer to either or both a and b is NO, code the question NO. 8. Do you feel anxious or uneasy in places or situations where you might have the paniclike symptoms we just spoke about? Or do you feel anxious or uneasy in situations where help might not be available or escape might be difficult? Examples include: Being in a crowd Standing in a line Being alone away from home or alone at home Crossing a bridge Traveling in a bus, train or car 9. Have you worried excessively or been anxious about several things over the past 6 months? Interviewer: If NO to question 9, answer NO to question 10 and proceed to question 11.

YES

NO

YES

NO

YES

NO

10. Are these worries present most days?

YES

NO

11. In the past month, were you afraid or embarrassed when others were watching you, or when you were the focus of attention? Were you afraid of being humiliated? Examples include: Speaking in public Eating in public or with others Writing while someone watches Being in social situations YES NO

12. In the past month, have you been bothered by thoughts, impulses, or images that you couldnt get rid of that were unwanted, distasteful, inappropriate, intrusive or distressing? Examples include: Were you afraid that you would act on some impulse that would be really shocking? Did you worry a lot about being dirty, contaminated or having germs? Did you worry a lot about contaminating others, or that you would harm someone even though you didnt want to? Did you have any fears or superstitions that you would be responsible for things going wrong? Were you obsessed with sexual thoughts, images or impulses? Did you hoard or collect lots of things? Did you have religious practice obsessions?

YES

NO

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SECTION B (CONTINUED)

13. In the past month, did you do something repeatedly without being able to resist doing it? Examples include: Washing or cleaning excessively Counting or checking things over and over Repeating, collecting, or arranging things Other superstitious rituals 14. Have you ever experienced or witnessed or had to deal with an extremely traumatic event that included actual or threatened death or serious injury to you or someone else? Examples Include: Serious accidents Sexual or physical assault Terrorist attack Being held hostage Kidnapping Fire Discovering a body Sudden death of someone close to you War Natural disaster YES NO

YES

NO

15. Have you re-experienced the awful event in a distressing way in the past month? Examples include: Dreams Intense recollections Flashbacks Physical reactions

YES

NO

PLEASE TOTAL THE NUMBER OF YES RESPONSES TO QUESTIONS 7-15

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SECTION C

16. Have you ever believed that people were spying on you, or that someone was plotting against you, or trying to hurt you?

YES

NO

17. Have you ever believed that someone was reading your mind or could hear your thoughts, or that you could actually read someones mind or hear what another person was thinking?

YES

NO

18. Have you ever believed that someone or some force outside of yourself put thoughts in your mind that were not your own, or made you act in a way that was not your usual self? Or, have you ever felt that you were possessed?

YES

NO

19. Have you ever believed that you were being sent special messages through the TV, radio, or newspaper? Did you believe that someone you did not personally know was particularly interested in you?

YES

NO

20. Have your relatives or friends ever considered any of your beliefs strange or unusual?

YES

NO

21. Have you ever heard things other people couldnt hear, such as voices?

YES

NO

22. Have you ever had visions when you were awake or have you ever seen things other people couldnt see?

YES

NO

PLEASE TOTAL THE NUMBER OF YES RESPONSES TO QUESTIONS 16-22

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SCORING THE SCREEN

NUMBER OF YES RESPONSES FROM SECTION A

NUMBER OF YES RESPONSES FROM SECTION B

NUMBER OF YES RESPONSES FROM SECTION C

TOTAL NUMBER OF YES RESPONSES FROM SECTIONS A, B, AND C Score > 10, assessment needed Score > 6 & < 9, assessment need should be determined by treatment team Score < 5, no action necessary unless determined by treatment team

YES RESPONSE TO QUESTION #4 If score = 1, assessment is needed

YES RESPONSES TO QUESTIONS #14 AND #15 If score = 2, assessment is needed

SCORE INDICATED NEED FOR AN ASSESSMENT? (CIRCLE) IF NO, DID TREATMENT TEAM DETERMINE THAT AN ASSESSMENT WAS NEEDED? (CIRCLE)

YES

NO

YES

NO

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Eight Gambling Screen

Early Intervention Gambling Health Test 1. Sometimes Ive felt depressed or anxious after a session of gambling yes, thats true 2. no, I havent

Sometimes Ive felt guilty about the way I gamble yes, thats so no, that isnt so

3.

When I think about it, gambling has sometimes caused me problems yes, thats so no, that isnt so

4.

Sometimes Ive found it better not to tell others, especially my family, about the amount of time or money I spend gambling yes, thats true no, I havent

5.

I often find that when I stop gambling Ive run out of money yes, thats so no, that isnt so

6.

Often I get the urge to return to gambling to win back losses from a past session yes, thats so no, that isnt so

7.

Yes, I have received criticism about my gambling in the past yes, thats true no, I havent

8.

Yes, I have tried to win money to pay debts yes, thats true no, I havent

Scoring Guide
If you answer YES to 4 or more questions gambling may be causing you problems in your life.

EIGHT Screen (Early Intervention Gambling Health Test) Developed by Dr Sean Sullivan Abacus Counseling & Training Services Ltd www.acts.co.nz

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Fagerstrom Test for Nicotine Dependence

1. How soon after you wake up do you smoke your first cigarette? After 60 minutes (0) 31-60 minutes (1) 6-30 minutes (2) Within 5 minutes (3)

2. Do you find it difficult to refrain from smoking in places where it is forbidden? No (0) Yes (1)

3. Which cigarette would you hate most to give up? The first in the morning (1) Any other (0)

4. How many cigarettes per day do you smoke? 10 or fewer (0) 11-20 (1) 21-30 (2) 31 or more (3)

5. Do you smoke more frequently during the first hours after awakening than during the rest of the day? No (0) Yes (1)

6. Do you smoke if you are so ill that you are in bed most of the day? No (0) Yes (1)

How did you do? If your score is below four points, your addiction to nicotine is not all that severe and you should be able to stop smoking fairly easily. If you score above seven points your nicotine dependence is high.

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The Payoff Matrix

Using Substances Advantages (as experienced by the client) Not Using Substances

Disadvantages (as experienced by the client)

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Aetiological Models

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While a number of vulnerability factors for the development of PTSD have been identified, most of these have minor effects. The biggest determinant of the development of PTSD is the nature and severity of the trauma, and whether the response to the trauma involved dissociation. This model considers PTSD to be comprised of four sub-syndromes, which has some empirical supported. Alcohol use prior to and at the time of the trauma appears to reduce the likelihood of PTSD developing. If it does, however, the risk of subsequent substance use problems escalates. Hyper-arousal appears to be the symptom most strongly related to the development of substance use problems. Clearly, drugs such as alcohol and cannabis are used to help reduce the hyper-arousal. High levels of arousal appear to generate rumination, which in turn increases re-experiencing and intrusive memories. Rumination may take several forms. Commonly, anger arises from rumination, and is activated by the arousal system. Anger may be specifically related to substance use. The implications of this model are that in those with PTSD and alcohol or cannabis use at least, treating the arousal is likely to be important.

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Vulnerability (Predisposing) Biological

Triggers (Precipitating)

Maintaining (Perpetuating)

Strengths (Protecting)

Psychological

Social

Spiritual

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Vulnerability (Predisposing) Biological

Triggers (Precipitating)

Maintaining (Perpetuating)

Strengths (Protecting)

Psychological

Social

Spiritual

Fraser Todd 2013