Key learning points:
- Non-judgmental screening is key to identifying people who are misusing substances
- Motivational interviewing skills and cognitive behavioural therapy techniques are useful to engage the patient in the process.
Substance misuse and its related issues are a global problem. In the UK alone it is estimated that over one-third (35%) of those aged 16-59 have used illicit drugs in their lifetime, with around 2.7 million people using a drug in the last year and an estimated one in 20 people using substances in the last month.1 The nature of drugs and drug-related problems places a significant burden on health and social services.2 As a result, it is imperative that both health and social services are staffed by an adequate workforce that has the right beliefs, attitudes and skills to work with people who experience problematic substance use.
As far back as the early 1990s, researchers believed that nurses and other health workers had the potential to ‘effectively respond to substance misuse problems and that their existing generic skills can be easily adapted in working with substance misusers’.3
Spotting the signs
The role of the nurse is particularly important in being able to identify and treat this group, and for many people practice nurses and the GP surgery may be their first point of contact with health professionals. Practice nurses are best placed to provide assessment and signposting to people with substance misuse issues. The use of screening tools in primary care can enable nurses to identify people with these issues, providing an entry point into health services.
Numerous organisations provide educational leaflets to help nurses spot the signs and symptoms of drug use. Many will list generic symptoms such as changes in mood, appearance, changes in appetite and sleep patterns. But these symptoms are not exclusive to people that may be misusing substances.4 It is important to independently assess each individual before jumping to conclusions.
For specific advice relating to the effects and side-effects of specific drugs, legality and costs, Drugwise provides an online drugs encyclopaedia, which provides an up-to-date assessment of substances that are likely to be misused, including over-the-counter medications and new psychoactive substances (NPS) which includes drugs such as methadrone.5
However, one of the best ways to understand how a substance may impact on someone is to ask them directly. Using open-ended questions about the positive and negative effects will enable a nurse to gain an understanding of some of the reasons for use as well as the maintaining factors for continued use. Branch and Willson believe that counting the cost of someone’s substance misuse is also a useful way to help clients explore the impact that substances have on their lives.6
Opening the conversation
The underlying rule for working with this client group is that if you ask the right questions, in the right way, people will discuss their issues. To begin that process there needs to be a clear identification of who is at risk. As mentioned previously, there are a significant number of people misusing substances, 1 in 20 in the last month1, and from all walks of life. The stigmatisation of substance misusers can restrict nurses’ perceptions of who they are, if we are truly to address the issue of substance misuse we need to universally screen people that have contact with services, not just people who ‘look like drug users’.
Some examples of ways to open conversations when assessing for substance misuse issues include:
- Using screening tools with all populations to identify people with substance misuse issues, without people feeling like they are being singled out.
- Asking for a full chronological history of substance misuse (including alcohol and cigarettes), the ‘what, when, how’ of their substance use. This may also highlight periods of abstinence, and discussion about how that was achieved can be useful in increasing self-efficacy.
- Asking about the positive and negative aspects of their substance use may help identify factors that keep them using a substance or can be a motivational exercise as it may highlight why change is necessary.
- Asking if a friend or relative has showed concern about their substance misuse can highlight areas of problematic use and help develop self-awareness.
Primary care provides a good opportunity for screening for substance misuse, as people may present with health problems that may not always be attributed directly to substance misuse. This first contact is sometimes referred to as the ‘gateway’ into the care setting. The Scottish Executive Effective Interventions Unit has created a digest of tools used in the assessment process and core data sets when working with drug users. These include an overview of tools that can be used for initial screening, to ensure appropriate referral to the correct service or a more in-depth assessment of people who misuse substances.7 Some tools used in initial screening include the Alcohol Use Disorder Identification Test (AUDIT), Severity of Dependence Scale (SDS), Personal Lifestyle Outcome Trace (PLOT) and the Substance Abuse Subtle Screening Inventory (SASSI).
Alongside these tools it is essential to engage the person using skills that transmit a non-judgmental approach. Motivational interviewing (MI) is a useful tool for working with people in relation to behaviour change. MI is described by Miller and Rollnick8 as a collaborative approach to explore and resolve ambivalence to change, using the client’s intrinsic motivations to change. The nature of MI is to allow the client to lead the session, with minimal guidance from the practitioner, using the clients’ agenda for change as opposed to the agaenda of the practitioners or service.9 MI uses of some of the skills of generic counselling (reflections, open-ended questions, for example); and the principles of being non-judgmental, expressing empathy and showing genuineness among many others.6
Prochaska and Diclemete’s transtheoretical model of change,10 also known as the cycle of change, is a useful tool for both nurses and patients to help illustrate and understand someone’s experience and their readiness for change. It is important to remember that even though someone may acknowledge that they have a substance misuse problem, they may not yet be at a point where they are able to change their behaviour. It is at this point that motivational interviewing and brief intervention may work particularly well.
Cognitive behavioural therapy
Cognitive behavioural therapy strategies have proved useful in the management of substance misuse, in particular with relapse prevention. Relapse prevention has been described as a tertiary intervention to reduce the possibility of relapse and to reduce risky behaviours that may make someone vulnerable to relapse.11 Some resources can be found on the Get Self Help website.
Multi-agency and multi-disciplinary working are essential to provide people with a wide-ranging package of care. More substance misuse care is coming under non-statutory services, particularly in the community. It is essential in these shifting times to keep up to date with the changes in service provision, and names and roles of services. Close partnership working can help practitioners keep up to date with any changes but can also provide the support and knowledge needed to give good packages of care to these patients.
It is worth mentioning that a lot of non-statutory services provide more flexible opening hours and provision, which can enable working people to access them without impacting on their jobs, thus helping to reduce some of the stigma associated with substance use. Some of the services that work nationally include; Turning Point, Lifeline and Change, Grow, Live (CGL). All provide websites detailing the geographical areas that they cover, as well as the role they play in relation to treatment services for specific groups. Local councils provide directories of local services that are a useful resources’.
In summary, when working with substance misuse issues in primary practice it is important to :
- Remain non-judgmental.
- Use recognised screening tools to assess people in primary care.
- Develop motivational interviewing and CBT techniques to engage with people.
- Develop knowledge of local and national services to provide multi-disciplinary support.
1. Home Office. Drug misuse: findings from the 1025/16 Crime Survey for England and Wales. Ed. Deborah Lader. Home Office and Office for National Statistics. 2016. Crown copyright.
2. Watson HE, McLaren W, Shaw F et al. Measuring staff attitudes to people with drug problems: the development of a tool. Effective Interventions Unit, Scottish Executive Drug Misuse Research Programme. 2001.
3. Rassool GH. Nursing and substance misuse: responding to the challenge. Journal of Advanced Nursing. 1993;18:1341-510.
4. Drugwise. What are the signs of drug use? drugwise.org.uk/what-are-the-signs-of-drug-use/ 2016. Accessed September 2016.
5. Drugwise. New Psychoactive substances. drugwise.org.uk/new-psychoactive-substances/ 2016. Accessed September 2016.
6. Branch R, Willson R. Cognitive Behavioural Therapy for Dummies. 2nd Edition. Wiley, 2010.
7. Scottish Executive Effective Interventions unit. Integrated care for drug users. Assessment. Digest of tools used in the assessment process and core data sets. 2003.
8. Miller WR, Rollnick S. Motivational Interviewing. Preparing People for Change. 2nd Edition. Guilford Press. 2002.
9. Sciacca K. Motivational interviewing in primary care. 6 clips. motivationalinterviewing.org/six-video-clips-motivational-interviewing-primary-health-care 2013. Accessed September 2016.
10. Prochaska J, Diclemente C. Stages and Processes of self change in smoking: toward an intergrative model of change. Journal of Consulting and Clinical Psychology 1983;5:390-5
11. Hendershot CS, Witkiewitz K, George WH et al. Relapse Prevention for addictive behaviour. Substance Abuse Treatment, Prevention, and Policy 2011;6:17