Addiction medicine

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Addiction encompasses a broad spectrum of disorders. These include substance use disorders (SUDs) for alcohol, tobacco and other drugs. It also encompasses behavioural addictions, such as addictions to gambling, food, sex, internet use and video gaming.1 The severity of these disorders can be classified as mild, moderate or severe.2 For many, they are chronic, relapsing disorders that require ongoing management, with lasting recovery seen in about half of all patients.3

SUDs are one of Australia’s leading causes of both fatal and non-fatal burden of disease. Tobacco smoking is Australia’s leading cause of cancer and preventable disease burden. Data also show that those living in the most disadvantaged socioeconomic areas are 3.6 times as likely to smoke daily when compared with people living in the most advantaged socioeconomic areas. Around one-third of Australian adults drink at levels that increase their risk of disease or injury. More than two in five Australians have used an illicit drug in their life, including prescribed medications used for non-medicinal purposes (eg benzodiazepines and opioids).4

The aetiology of SUDs and other addictive behaviours is complex and includes, but is not limited to, individual genetics, personality, comorbid conditions, and the social and environmental determinants of health.5 While all patients may be at risk of substance use and addiction disorders, some patient groups are at increased risk, including:4,6

  • Aboriginal and Torres Strait Islander peoples
  • people with mental health conditions
  • people identifying as lesbian, gay, bisexual, transgender, intersex, queer or questioning (LGBTIQ+)
  • people with experiences of trauma.

General practitioners (GPs) play a variety of roles in addiction management, from screening and diagnosis to primary prevention, treatment and referral, as required. GPs should familiarise themselves with the types of substances and behavioural addictions that are problematic in their community, and should screen all patients for use of tobacco, alcohol and other drugs (AOD), including prescribed medications, such as benzodiazepines and opioids. They should also be aware of the psychological therapies and pharmacological treatments (eg methadone, buprenorphine) that are available for patients experiencing addiction.6,7

Given the intersection between addiction, comorbidity and social determinants of health, treatment involves taking a patient-centred, whole-person-care, chronic disease approach. Trauma often accompanies addiction. The provision of trauma-informed care is therefore essential, as is the consideration of barriers to access and engagement with treatment,5,6 such as rural or remote location and lack of access to addiction specialist services. Treatment should use a strengths-based approach and recognise that recovery is possible. Established family and community supports are considered protective factors and should be included in treatment plans. As with all chronic diseases, treatment and ongoing reviews of substance-related and addictive disorders should be regular, planned and long term. Facilitating patient autonomy, consent and confidentiality in treatment is also essential.5

Many people with addiction have experienced discrimination and/or had negative experiences when interacting with health services. A non-judgemental, stigma-free approach is therefore essential when screening and treating patients with substance-related and addictive disorders.5,6 Stigma and health literacy can form barriers to seeking treatment.8,9 GPs should reflect on their own practice, the role of stigma and discrimination, and familiarise themselves with appropriate accepted language within addiction medicine.

Clinical governance and ethical issues are important in addiction medicine. Prescribing addictive scheduled medications is highly regulated.10 GPs therefore need to understand the legalities around these, as well as prescription monitoring software in their jurisdiction. GP collaboration with regulatory bodies, specialists and patient groups will also continue to inform these regulations.

References
  1. Grant J, Chamberlain S. Expanding the definition of addiction: DSM-5 vs. ICD-11. CNS Spectr 2016;21(4): 300–03. doi: 10.1017/S1092852916000183
  2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edn. Washington: American Psychiatric Association, 2013.
  3. Substance Abuse and Mental Health Services Administration (US). Facing Addiction in America: The Surgeon General's report on alcohol, drugs, and health. SAMHSA (US), 2016 [Accessed 28 September 2021].
  4. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019. Canberra: AIHW, 2020 [Accessed 10 June 2021].
  5. Marel C, Mills KL, Kingston R et al. Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings. 2nd edn. Sydney: Centre of Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales, 2016. Available at:
  6. Australian Government Department of Health. National Framework for Alcohol, Tobacco and Other Drug Treament 2019 -2029. Canberra: Department of Health, 2019 [Accessed 1 June]
  7. Australian Institute of Health and Welfare. Alcohol and other drug treatment services in Australia annual report. Canberra: AIHW, 2021 [Accessed 12 October 2021].
  8. Australian Drug Foundation. Stigma and people who use drugs. ADF, 2019 [Accessed 10 September 2021].
  9. Australian Institute of Health and Welfare. Health literacy. Canberra: AIHW, 2020 [Accessed 10 September 2021].
  10. The Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice. East Melbourne, Vic: RACGP, 2015.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate a non-judgemental attitude when communicating about addiction and substance use
1.1.2, 1.2.1, AH1.3.1 
  • use communication skills to develop an understanding of why people have developed an addictive behaviour, and work with them to find a solution 
1.1.1, 1.3.1, 1.4.3
  • use a range of communication skills to interview and counsel patients and their families about substance use and addictive behaviours
1.1.1, 1.1.2, 1.1.4, 1.1.6, AH1.3.1, RH1.3.1
  • use awareness of sociocultural factors affecting people with substance use and addiction in order to make appropriate community referrals  
1.3.1, 1.4.2, 1.4.3, AH1.4.1, RH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • perform a thorough screening interview that includes questions about substance use and other addictive behaviours, such as gambling 
2.1.1, AH2.1.1
  • identify a patient in withdrawal and offer appropriate treatment options, taking into account patient autonomy and harm minimisation
2.1.3, 2.1.8, 2.3.1, 2.3.3, 2.3.4, RH2.3.1
  • use comprehensive, collaborative management plans to manage patients with addiction 
2.1.9, 2.2.2, 2.3.1, 2.3.2, AH2.3.1 
  • prescribe and de-prescribe addictive scheduled medications in a manner that is safe and in accordance with regulation
2.1.8, 2.1.9, 2.2.2
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify and screen patients at increased risk of addictive behaviours
3.1.1
  • implement strategies to prevent and minimise harm for those patients who are more vulnerable to addiction
3.1.4, RH3.2.1, AH3.2.1 
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • facilitate a practice-wide approach to managing patients with addiction by maintaining personal wellbeing and boundaries, and supporting colleagues 
4.1.4, 4.1.5, 4.2.3, 4.3.3
  • reflect on personal biases regarding addictive behaviours and how these impact clinical care
4.2.1, 4.2.2, 4.2.4, AH4.2.2
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate an understanding of confidentiality and consent for people with addiction  
5.2.1, 5.2.2
  • identify and implement ways to create a practice environment that is safe and free of stigma towards patients with addictive behaviours
5.1.1, 5.2.5, 5.2.6
  • routinely document screening of smoking, AOD use in clinical notes
5.2.3
  • demonstrate an understanding of the legislative and regulatory framework that governs prescription of addictive scheduled medication, including Schedule 8 drugs and the substances used to manage opioid dependence
5.2.3, 5.2.4, 5.2.5 

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Consider taking the social history first to learn about the patient. Why are they taking drugs? Many will have a history of trauma. Developing a therapeutic relationship with patients is the main tool the GP has to change the lives of people suffering from addictions. A non-judgemental and curious approach, and the setting of appropriate boundaries, are the keys to successful outcomes.
  2. Take the substance use history as part of the past medical/medication history. This avoids implying that a patient’s drug use is ‘just a lifestyle choice’ and something to be embarrassed about discussing. Anyone can have a substance use issue. Take a substance use history routinely to avoid surprises.
  3. Partner with a buddy to manage drug-using patients. This provides more support for both doctors and patient. Listen to your gut feeling: resist requests or actions that make you feel uncomfortable.
  4. Practising addiction medicine is rewarding. You can have a big impact on people’s lives. Addiction medicine is good training for keeping an open and flexible mind. You can’t afford to prejudge, and some patients will keep your eyes open and your mind searching for strategies.
  5. ‘Drug, set and setting’ is an old concept in addiction medicine. It explains the interaction between intrinsic properties of the substance, the physical and psychological mindset of the person, and the cultural setting of the use. It is a useful framework in which to explore an individual’s addictive behaviours and to inform brief interventions and other treatments.
  6. Controlled substance use or modified behaviour is a much-desired outcome for many patients; however, patients who attempt controlled use/behaviour often find that they rebound to equal or greater episodic use/behaviour. For example, a smoker may cut down for two or three days, but then relapse to greater use. This can be dangerous if a substance with lethal potential is involved. For this reason, it is often better to champion abstinence at least for a period of time. Understand, however, that patients may not agree with you, so provide information to allow them to make a fully informed choice.
  7. Brief interventions are an opportunity to engage, motivate and reduce harm to patients.
  8. Some patients hope that you will be able to ‘fix’ them, but addiction cannot be fixed with a medication or procedure. Much of the conflict in treating addiction – overprescribing, doctor burnout, rejection by addiction patients – arises from this impasse. By setting treatment goals that encourage a patient’s autonomy, self-efficacy, self-worth and reintegration with family and community, you are more likely to achieve recovery, patient respect and doctor satisfaction.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Addiction medicine

You are a GP in a thriving regional centre. Sam, a 58-year-old store person and forklift driver, presents requesting prescribed cannabis. Sam started using cannabis six years ago. He suffered a herniated disc and prolonged pain, for which he was prescribed oxycodone and codeine products for several months. He wonders if cannabis can be prescribed to him now, as he is finding the cost, and the occasional lack of availability, difficult to deal with. Sam says the cannabis is useful for relieving his pain.

Questions for you to consider Clinical exam assessment area Domains

What communication strategies would you use to engage Sam?

How would you develop rapport and get the clinical information you need? How would you sensitively ask about Sam’s protective and risk factors, such as his family situation?

How might you adjust your communication if Sam became defensive or tense during the consultation?

What if Sam did not speak English well?

  1. Communication and consultation skills
1,2,5
 

What specific information about Sam’s substance use do you need to make an accurate assessment and develop a management plan?

What further information would you like about Sam’s past medical history?

What examination would you perform?

  1. Clinical information gathering and interpretation
2   

Does Sam have a substance use problem? What are the reasons for your conclusion?

Does Sam have a pain condition?

Would it change your clinical interpretation if Sam told you that he drinks six mid-strength beers and smokes 20 cigarettes daily? What further information would you like to know about this?

What if Sam had features of depression, anxiety or other mental health issue?

Would it affect your diagnosis and management if Sam had had a substance use disorder in the past? 

  1. Making a diagnosis, decision making and reasoning
2   

What factors are important to inform your management plans for Sam? How would you weigh the risks and benefits of each management option?

How would your approach change if Sam had comorbid anxiety?

What medications might be useful for Sam? What if he had a family history of psychosis?

If Sam were an Aboriginal or Torres Strait Islander, how would this change your management?

What services might you access for Sam? What other services might be available if Sam identified as LGBTIQ+?

How could you help Sam if he lived in a remote location? How could you access timely services for him?

  1. Clinical management and therapeutic reasoning
2   

How would you assess the risks to Sam and to his partner and children from his drug use?

What preventive activities are important for Sam? How would you discuss harm minimisation and develop an action plan with Sam and his family?

What changes could you advocate for in your practice and community to improve care of substance-using patients?

  1. Preventive and population health
1,2,3      
 

How would you counsel Sam if you decide that cannabis is not indicated?

What personal biases do you need to be aware of in managing Sam?

What are the ethical concerns for both patient and doctor in using a medication ‘off label’ when evidence of benefit is not proven in clinical trials?

  1. Professionalism
4   

Is Sam able to access prescribed cannabis?

How could you check his drug use history further?

How would you advise Sam about the regulatory issues involved in his current and potential substance/medication use; for example, with respect to his occupation or driving?

  1. General practice systems and regulatory requirement
5   

What clinical tools could help you manage Sam?

  1. Procedural skills
2   

What if you found out that Sam’s wife also smoked cannabis?

What if Sam later admitted to you that he was also on an opioid substitution program? What action would you take?

  1. Managing uncertainty
2   

What do you need to look out for in monitoring Sam if he engages in treatment with you?

How would you identify drug-induced psychosis?

What would be your management if Sam presented to an appointment intoxicated or in withdrawal?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Reflect on the power and vulnerability of the patient–doctor relationship. Consider a patient/s you have seen with an addiction disorder.

  • What was the patient’s level of health literacy? How did this affect their engagement with you and participation in treatment?
  • Did they make progress as you expected? What were their protective and risk factors?
  • Reflect on your personal response to this patient. Did you find any barriers to providing care to them? How did their life experience differ from your own?

Make a summary sheet of the recommended guidelines for treatment of nicotine, alcohol and amphetamine opioid addiction. Compare how each is managed.

  • What is the evidence for these treatment recommendations?
  • When comparing the different approaches and treatments available, what surprised you? Are there anomalies or insufficiencies in how each is treated? How does this relate to patient management? Is your practice evidence based?

Arrange a visit to your closest addiction medicine specialist unit or hospital consultation-liaison service. Ask the medical or nursing staff to supervise you. Focus on obtaining skills in examining patients with substance use disorders (SUDs).

  • What examination and screening tools does the clinic use to assess patients? How often are they used and for which substances?
  • What are the pros and cons of urine drug screening and what is the best way to use it?
  • Which comorbid medical and psychological conditions are routinely screened for?

Audit a sample of your practice records to identify how many patients have completed information about their smoking, alcohol and drug use. Analyse recalls for patients with addiction to alcohol, tobacco and other drugs.

  • How is information about addiction recorded in your practice? Where in the consultation is it recorded? How does your software ensure information about addiction is recorded promptly?
  • Are there practice policies related to recall of patients with addiction? What systems are in place to achieve equity for Aboriginal and Torres Strait Islander substance-using patients in your practice?
With a supervisor

Keep a record of complex interactions with substance-using patients. Discuss with your supervisor how a particular interaction affected you, and how you could resolve any issues it raised.

  • What was it about the interaction that made you feel uncomfortable? Did the discussion with your supervisor help you resolve this? What part of the discussion did you find helpful and why?

Review or develop a protocol related to an area of substance use treatment in your clinic. Discuss your new or reviewed document with your supervisor. Consider presenting it at the next practice meeting. Ask your colleagues to give you feedback about how it could be improved.

  • How did you go about identifying an area to review? What did you consider in developing a new guideline? Will this add or remove barriers to substance-using patients attending your practice?

Ask your supervisor to sit in on one of your SUD consultations. Afterwards, review your history-taking and patient examination with your supervisor.

  • What feedback did your supervisor give you? Did they have any suggestions for managing this type of consultation?
  • What examination was required?
  • What is the appropriate type of language to use when talking about substance use in a consultation? How do you avoid using stigmatising language, including body language?
In a small group

Have each person in the group present an addiction medicine case. If you have not had a case before, make up a case study. Develop comprehensive management plans for these cases. Identify the substances used in your community and the withdrawal syndromes that may present. Discuss how you treat these in your practice and what could be improved. Ask your local pharmacist to attend your discussion to talk about the substance use issues they see.

  • Did everyone reach similar conclusions about each patient’s management? What does the literature say about each case? How were alternative management strategies and options explored? What differences in approaches to treatment might exist in different practices?
  • How could treatment be improved in your community?
  • How could you partner with the pharmacist in managing patients with addiction?

Discuss consent to treatment for patients with addiction. Identify the ethical principles of informed consent that are most relevant to substance-using patients.

  • What information is important to include when obtaining informed consent from patients being treated for drug and alcohol dependence? How would you assess a patient’s motivation? How would you assess their understanding of treatment options? What if the patient had an acquired brain injury?
  • What is the role of coercive treatment in addiction treatment? What impact might this have on a patient’s motivation and engagement?
  • hat potential risks to patient confidentiality are inherent in alcohol and drug treatment?

Do two role plays of an initial consultation for a patient seeking assistance with substance use. Use judgemental, stigmatising language in the first, but not in the second.

  • What communication strategies were used in each version of the role play?
  • What is the effect of using a structure that places the social history first in the consultation? How do patients respond to this?
  • What topics and communication strategies engage patients?
With a friend or family member

With a friend or family member, watch a movie that has substance use in its theme. Explain your view of the substance use depicted and how you would address it if the person in the movie were to consult you.

  • In explaining what you would do, what would be important for your friend or family member to hear about your work? What parts are difficult to explain? What makes it difficult?

Have a discussion with a trusted friend or family member about stereotypes of substance-using people.

  • What personal biases or prejudices do you have? What about your friend or family member? Do they have different views?
  • How can your biases impact your ability to effectively care for substance-using patients? How could you challenge your perceptions?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Use effective communication skills, including non-stigmatising language, and a positive attitude to support the health of substance-using patients.
  • Using non-stigmatising language and with a positive attitude, identify and manage barriers to communication and engagement with substance-using patients. Potential barriers for patients include:
    • lack of knowledge about, or confidence for, change
    • low health literacy
    • coercion, such as court-mandated treatment
    • past trauma or violence
    • cost of treatment
    • lack of family and community support.
  • Perform motivational interviewing informed by a cycle-of-change model to promote healthy behaviours and prevent the negative effects of substance use. Brief interventions may include:
    • exploring reasons for change and preventing relapse
    • advising about safe use of alcohol, smoking cessation, safer injecting and optimal medication use
    • providing harm-minimisation advice specific to substance
    • providing preconception and prenatal advice about substance use
    • preventing suicide  
    • providing access to information to empower patients and develop their life skills.
  • Proactively identify substance use by regularly screening patients, asking about use of nicotine, alcohol, illicit drugs and prescribed medications, such as sedatives and stimulants. 
  • Assess use of substances, including type, amount and circumstances of substances used and their effects. Examine patients physically for signs of substance use, intoxication and withdrawal.
  • Safely manage acute health issues consequent to, or associated with, substance use.
  • Work with legal and community agencies to manage consequences of substance use, such as where child protection is required.
  • Manage substance use as a chronic health condition. Conditions include:
    • acute intoxication, overdose
    • acute withdrawal syndromes
    • drug-induced psychosis
    • mental health conditions
    • medical comorbidities, including hepatitis C and B and HIV, liver disease, thrombophlebitis, sexually transmissible infections, cardiovascular disease
    • social dysfunction – occupational, relational, financial, criminal effects, trauma
    • pain.
  • Provide preventive care to substance-using patients, including:
    • health checks
    • routine screening
    • ensuring vaccinations are up to date, especially hepatitis B
    • in pregnancy.
  • Understand evidence-based treatments and the requirements for monitoring their use, including:
    • rehabilitation services
    • naloxone for harm reduction
    • hiamine in alcohol dependence
    • monitoring pharmacotherapy/drug use:
      • methadone
      • buprenorphine/naloxone
      • anti-craving medications
      • withdrawal medications
      • nicotine replacement.
  • Engage in multidisciplinary care.
  • Understand and manage behavioural addictions, including gambling.
  • Work systematically to improve the health of patients with addiction, understanding:
    • the prevalence of substance use and behavioural addictions in the community
    • the peak age incidence of addictions
    • the impact of substance use/behavioural addiction on individuals, families and the community
    • the special needs of high-risk groups; for example:
      • Aboriginal and Torres Strait Islander peoples
      • people with mental health conditions
      • LGBTIQ+ people
      • culturally and linguistically diverse populations
      • people who inject drugs
      • sex workers
      • people recently released from prison
      • the rural population.
  • Engage in health advocacy to develop supportive environments, expand services and promote community knowledge of addiction.
  • Facilitate informed consent for treatment, considering capacity for consent; manage refusal of treatment.
  • Observe recall and follow-up protocols for substance using and behavioural addiction patients.
  • Understand and follow regulations related to prescribing medications to drug-dependant patients.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
How to prescribe cannabis safely. Evidence of the link between better health outcomes and quality patient–doctor interactions.
Textbooks
A comprehensive text on addiction medicine and a good read.
  • Saunders JB, Conigrave KM, Latt NC, Nutt DJ, Marshall EJ, Ling W, Higuchi S, editors. Addiction Medicine. 2nd edn. Oxford: Oxford University Press, 2016.
Online resources
National directory of AOD treatment services for Aboriginal and Torres Strait Islander peoples. Available on iOS and Android devices. ACON responds to health issues affecting the LGBTIQ+ community. Pivot Point is their education arm and provides self-help guides for patients. Indispensable guide to issues in substance use and drug withdrawal. It includes tools for assessing withdrawal and mental health status. The definitive guidelines for treating addiction in general practice. They include information about benzodiazepine and opioid prescribing, prescribing regulations, smoking cessation and pain management, and advice about the Aboriginal and Torres Strait Islander health check item and patient management of smoking, alcohol, gambling and illicit drug use.
Learning activities
This program includes a resource library and access to AOD Connect: Project ECHO, which provides an opportunity to discuss AOD patient cases with peers. Two examples of the many AOD modules available at RACGP Events. Insight is Queensland Health’s centre for AOD training and workforce development. Their eLearning series is a useful resource and the information provided is succinct. This particular course is open to all GPs. gplearning has a number of helpful activities.
  • The Royal Australian College of General Practitioners. gplearning
    • Alcohol and other drugs: At-risk groups – Trauma
    • Alcohol and other drugs: Facilitating behaviour change
    • Alcohol in pregnancy
    • Benzodiazepine prescribing in general practice.
Other
The Victorian Drug and Alcohol Clinical Advisory Service (DACAS) is a telephone consultancy service that is free for health and welfare professionals. GPs can call at any time of day for specialist advice on patient management. Resources for treating young people.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/addiction-medicine 6/10/2022