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How do I ask?

Conducting a good patient interview is essentially about being open and non-judgmental, and enabling patients to express their concerns in a way that helps them identify the problems and take the next step towards addressing problems related to their drug use.

Display

interest and attention
empathy
warmth
active listening skills
thoughtfulness (wisdom and knowledge)
reflectiveness
an inability to be shocked
a non-judgmental stance that does not blur into collusion
a style of questioning that enquires in an open, non-confrontational way about simple, recent issues

Be Vigilant

Indicators of AOD problems may include:

domestic violence (actual or threatened)
risks for children (e.g. neglect or intoxication-related harm)
social isolation
anxiety / depression
stress management
other drugs used to self-medicate

General practice and primary health care offer a variety of opportunities to enquire about alcohol and drug use. For example, in the context of:

a new patient assessment - as part of initial information gathering
management of chronic problems - alcohol for example, is a risk factor in cardiovascular disease, diabetes, depression
management of acute problems, especially trauma, gastrointestinal disorders, anxiety / stress, psychological problems
preoperative assessment
pre-conception and antenatal care
enhanced Primary Care Medicare Benefit Schedule items - health assessment, care plans and case conferences

Although AOD problems may be the primary presenting problem, they are more commonly detected when the patient presents for another issue.

Just Ask

Low key, generic questions that are useful include:

'These days many people use alcohol or sometimes other drugs to relax, how about you?' or
'Many of my patients drink alcohol, do you?' or
I'd like to ask a few questions about your general lifestyle.
- Tell me about your diet?
- How much exercise do you get?
- Do you smoke?
- Drink alcohol?
- Take other drugs?

If the patient answers 'yes' to any of these last questions probe further and seek specific information about quantities and frequencies. Do not settle for vague responses such as 'I'm a social drinker.'

Early Recognition of Alcohol-related Problems

More likely to be identified early when the health professional:

is aware that psychosocial problems occur before most physical problems
is willing to follow up with detailed enquiry and appropriate investigations

Assessment

Helps the doctor and patient, working together, to link high-risk AOD use to:

past life experiences and expectations
lifestyle, social and occupational factors
physical and psychological conditions
motivations for reducing / ceasing AOD use

Assessment is essential for formulating an individually tailored and negotiated treatment plan.

Some specific drug-related questions to consider include:

"When did you start using XXX?"
"Have you stopped before and if so, for how long?"
"What led you back to using?"
"Have you had any treatment and what was the outcome?"
"What do you like about using drugs?"
"In what ways does drug use help you to cope?"
"What concerns you about your drug use?"

A comprehensive assessment can:

bring some clarity (to both patient and doctor) about what may seem like a "chaotic array of happenings"
build rapport and instil a sense of direction
indicate areas in need of urgent attention
identify areas that will benefit from harm minimisation strategies
provide a basis for treatment recommendations

Screening Questionnaires

Use of general questionnaires covering lifestyle issues such as smoking, diet, exercise, alcohol and drug use may be less threatening and stigmatising for patients. There are also a number of short, well-validated questionnaires that can be used to screen for alcohol problems. Screening and brief interventions can readily be combined in a single general practice consultation.
AUDIT, (AUDIT - Interview Version: Handbook, Appendix C (PDF 48 KB) & AUDIT - Self-report Version: Handbook, Appendix D (PDF 46 KB))

Biological Screening

A number of blood tests can be used to screen for alcohol problems. However, they can be less sensitive and specific than questionnaires.

These screening tests include:

full blood count, including MCV
liver function tests, including gamma GT
triglycerides
NHMRC Alcohol Guidelines - Short and Long-term Risks: Handbook, Appendix A (PDF 49 KB)

Urine Testing

Can detect alcohol, other drugs (e.g. cocaine, opioids cannabis, benzodiazepines and barbiturates) and / or their metabolites.

Screening tests for drug use include:

full blood count, including white cell count
liver function tests
hepatitis B and C and HIV serology

For more information about assessment, see the Assessment topic in the Resource Kit

Common Clinical Presentations

Indicators of alcohol- or drug-related problems are wide-ranging and can involve

cardiovascular
gastrointestinal
musculoskeletal
neurological
dermatological
genito-urinary systems
accidents / trauma, social and legal incidents

Indicators of problematic drug use can include:

infections (injecting users)
accidents / trauma
psychiatric problems
behavioural, social and legal incidents

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