Alcohol and drug use in Australia has increased during the COVID-19 pandemic¹. It affects many presenting complaints and is associated with many common comorbid conditions. Screen opportunistically and remember that each patient’s substance use will change and evolve over time. Screening and assessment are not a one-off occurrence but should be periodically repeated.

There are several different opportunities where you can incorporate an AOD assessment within a consultation. These include consultations where:

• a broader assessment is being made (eg new patient, setting up a chronic disease management plan, and other health assessment type consultations)
• the patient’s presenting issue offers an opportunity to explore potential AOD co-factors (eg a sprained ankle and alcohol use, palpitations and stimulant use, falls and sedative use)
• the patient’s existing medical history offers opportunities to explore AOD co-factors (eg mental health conditions and many substances, bowel cancer and alcohol, hepatitis and injecting drugs).

Yes, the words and tone we use when speaking with patients who use substances can have an impact on access and delivery of care. Fear of judgement and stigma directly harms people who use alcohol and other drugs. It creates barriers to them asking for help, accessing treatment and often results in poorer quality care.² Language and words that strengthen the therapeutic relationship are preferred. These foster acceptance, inclusion, and safety instead of judgement, stigma, and fear.

Resources

• The power of words: Having alcohol and other drug conversations - A practical guide
• Australian Journal of General Practice - How stigmatising language affects people in Australia who use tobacco, alcohol and other drugs
• Network of alcohol and other drugs agencies - Language Matters

Substances can be categorised in many ways. Broadly speaking, substance types include depressants, stimulants, opioids, psychedelics, cannabinoids, dissociatives, and empathogens. 

Resources

• Australian Drug Foundation Drug Wheel
• Touchbase – Alcohol and Drugs
• Your Room – A-Z Listing of Drugs

The general rule of thumb is, if you’re unsure, ask your patient. The patient is the expert on their substance use. Street names of common illicit substances include:

Resources

• Dovetail – AOD Acronyms and Slang Dictionary
• Alcohol and Drug Foundation – Text the Effects 

Use motivational interviewing when talking to patients about their substance use.⁴ This collaborative, evidence-based approach honours patient autonomy and supports behaviour change.
 
Make the discussion conversational, especially if you are asking about a patient's substance use for the first time. Ask permission to ask them about their substance use and don’t pursue it if the patient declines. Normalise the questions, provide the context of why you are asking, and use their presenting problem to explore their substance use. Take it at the patient’s pace and be mindful that you may need to talk about their substance use over multiple consults.
 
Remember to ask open-ended questions, explain why you are asking the question, give the patient choice to answer and reassure the patient about confidentiality. Directive, close-ended questioning risks the patient feeling interrogated or judged.

Reasons why patients use substances are complex and impacted by a wide range of biopsychosocial factors that will vary from person to person. Some population groups do have a higher risk of harms associated with their substance use⁵. These include Aboriginal and Torres Strait Islander peoples, lesbian, gay, bisexual, transgender, intersex, queer, asexual and other sexually or gender diverse (LGBTIQA+) people, people experiencing homelessness, older people, younger people, and those from culturally and linguistically diverse backgrounds. Those with mental health conditions, who have experienced trauma, have been in contact with the criminal justice system, or inject drugs, are also at higher risk. Refer to the resource links in the AOD Resource List at the bottom of this page under Priority Populations.

One standard drink equates to 10 grams of alcohol. There are around 7 standard drinks in a bottle of wine, about 1.4 standard drinks in a full-strength beer and 22 standard drinks in a bottle of spirits.⁶
 
The current Australian Alcohol Guidelines 2020 (NHMRC) recommend 10 drinks (100 grams) per week to maintain low risk drinking for both males and females, and no more than 4 drinks (40 grams) on any one day. There are no established safe drinking levels for women who are pregnant or breastfeeding. Children and people under 18 should not drink alcohol.

Resources

• Drinkwise – Calculate your alcohol intake
• Australian Government Department of Health – Australian Alcohol Guidelines Revised

Use the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) screening tool to determine whether the patient is drinking within low-risk levels OR if their drinking exceeds low risk levels. Using a drinks calculator or standard drinks chart can help patients. For access to the AUDIT-C screening tool and recommended interventions and approaches following AUDIT-C, refer to the following AOD screening and withdrawal toolkits.

Resources

• NCETA, Flinders University – AOD Screening Tools Collection
• NCETA, Flinders University – AOD Withdrawal Tools Collection
• Drinkwise – Calculate your alcohol intake

Not all alcohol and drug use is problematic. Biopsychosocial factors discovered during your assessment may indicate that the substance use is leading to health problems. Other patients may be at risk of problems developing.
 
A substance use history may take several visits to conduct. Screen regularly and assess based on the potential risk of harm. Consider offering 1-2 minutes of harm minimisation advice. Leave the door open for patients to return and discuss their substance use when they are ready. This isn’t condoning their use but supporting your patient with their health at their specific stage of change.
 
Assess a patient’s substance use based on their last use, the typical amount they use, how they use (eg smoke/inject), their frequency of use, the duration of use, the effects of use and their stage of change. While you might not need to assess each of these components, it can help you determine how to pitch your harm minimisation advice according to the potential risk of harm, and the reasons why the patient is using the substance(s).

The ASSIST Lite screening tool can be used by you or your patient, without entering any identifying information. The tool will take several minutes to complete and can be used for a wide range of substances. Once the screen is complete, a downloadable resource is available providing harm minimisation advice and recommendations for treatment approach. For a comprehensive assessment, GPs are recommended to use the eASSIST Lite tool.

Resources

• University of Adelaide – ASSIST tools and resources
• University of Adelaide – eASSIST-Lite online screening tool
• NCETA, Flinders University – AOD Screening Tools Collection

A substance use disorder (SUD) is a chronic disease that involves the development of physiological, psychological, and social symptoms. It is classified as mild, moderate, or severe according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 

Psychological and behavioural symptoms include ongoing use of substances despite harms to relationships, reputation, physical and mental health, and leisure time. There may also be an increase in time spent finding and using substances, an inability to reduce their use, and using in risky situations. Physiological criteria relate to the development of tolerance and withdrawal. At least two of the mentioned symptoms need to occur for an SUD to be diagnosed.  

Patients that develop an SUD are more likely to be using substances to cope with physical or psychological pain and are more likely to have co-occurring mental health disorders or a history of trauma. 

Resources

• DSM-5 criteria for diagnosing an SUD
• DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale