Attending to alcohol and drug misuse in the mental health sector: should it be routine practice ?

Nursing Education Forum, Wellington,12 & 13 November 2009

David Newcombe

School of Population HealthFaculty of Medical and Health SciencesUniversity of Auckland

Introduction/aims

• My personal journey• Working in the addiction

sector• University of Auckland –

training - combining practice with theory

• An insight into relevant research

• Moved to Aus when 13 years old

• Lived and worked in many places in Aus– Tasmania– Outback NT– Queensland– South Australia

• Moved to New Zealand - 2006

My Personal Context - Early Career

• Nursing • General training- Royal Adelaide Hospital • Post Graduate Intensive Care & Burns

Nursing Course in England– most notable event – met my wife– and learnt lots as well !

• On return to OZ Worked in Melbourne and Adelaide Burns units

• Awareness of link with A&D use/ mental health issues and injury

• Impetus to learn more about human behaviour

University training

• Flinders University of South Australia - Psychology training

• Worked as a psychology lecturer whilst undertaken post graduate psychology training

• PhD – Psycho pharmacology (addictions) at the University of Adelaide

Working in the A&D sector

• New South Wales– General A&D counsellor– Manager MERIT team– GP/Pharmacy liaison officer

• South Australia– Regional Drug and Alcohol Services - Research

manager – Worked in WHO Collaborating Centre for Alcohol and

Drug Treatment

New Zealand Beckons

• Academic position in the A & D area • Post graduate co coordinator Alcohol and Drug

Studies• Unique course – combines practice and theory

and builds on students existing professional training

• Permits professionals from a variety of professional backgrounds to gain knowledge base in Addictions

Establishment of Academic Establishment of Academic credentials - its taken time credentials - its taken time

1995 – First post-graduate course 1995 – First post-graduate course

1997 – First intake for PG Certificate (with 1997 – First intake for PG Certificate (with government funding)government funding)

1999 – First students take PG Diploma1999 – First students take PG Diploma

2001 – Diversified courses on dual 2001 – Diversified courses on dual diagnosis, gambling, biology etc.diagnosis, gambling, biology etc.

2008 – Qualification established2008 – Qualification established

Core courses

• Assessment & Intervention with Addiction– Full year course, clinical

skills based with supervision and clinical observation assessment

• Alcohol, Tobacco & Other Drug Studies– Half year course,

introduction to theory & research

Elective courses

• Biology of Addiction – Neurobiological basis of addiction and overview of

pharmacotherapies used to treat A&D dependence

• Theory and skills in counselling practice – Overview of therapeutic approaches and skills

• Coexisting substance use and mental health disorders – I: Foundations - theory– II: Interventions

Other courses continued

• Interventions for Lifestyle Change– Work on design of projects relevant to area

• Gambling and Health • Tobacco Control • And able to choose from a wide variety of

culturally based and mental health papers

Current Qualification Layers

• Tiered framework allows students to leave with the qualification that matches their needs and abilities– Post-graduate Certificate in Health Science

(Alcohol & Drug Studies) – Post-graduate Diploma in Health Science

(Alcohol & Drug Studies) – Masters in Health Science

• Research Masters and PhD

Relevant Research – practical issues

• Attending to alcohol and drug misuse in the mental health sector: should it be routine practice ?

• If it should be then how can mental health practitioners detect alcohol and drug misuse amongst consumers?

Relevant Research – practical question• There is a need for a universal screening tool that has

been validated for use with people who have mental health issues

• For example: The AUDIT – alcohol – validated for use amongst people with MH problems

• Linked to brief intervention • Or facilitates referral to specialist centre• But only screens for one substance• Development of the ASSIST is promising

What is the ASSIST?

• Alcohol, Smoking & Substance Involvement Screening Test

• 8 item questionnaire (paper & pen)

• Administration time ~5-10 minutes

• Developed for health care workers in primary care settings

• Validated in a variety of cultures

• Designed to be linked to a Brief Intervention

What does the ASSIST do?

• Screens for risky substance use• Alcohol, tobacco, cannabis, cocaine,

amphetamine-type stimulants, sedatives, hallucinogens, inhalants, opioids, ‘other drugs’

• Determines risk score for each substance • Current use (last 3 months)

• Lifetime use

• Score provides an opportunity to start discussion (Brief Intervention) with client about their substance use

The ASSIST – an overview

• Questions asked for all substance groups

• Lifetime use – Q1 Ever used Which of the following have you ever used ?

The ASSIST – an overview• Last 3 months – current use

– Q2 Frequency of use

In the past 3 months, how often have you used the substances you mentioned?

– Q3 Desire to use [Dependence]

How often have you had a strong desire or urge to use ?– Q4 Health, social, legal, financial problems

How often has your use of (first drug etc.) led to health, social, legal, or financial?

– Q5 Failure to fulfil role obligations

How often have you failed to do what was normally expected of you because of your use of (first drug, second drug, etc ?)

The ASSIST

• Lifetime use– Q6 Concern by othersHas a friend of relative or anyone else ever

expressed concern about your use of (first drug etc.)?

– Q7 Failed attempts to control use [Dependence]

Have you ever tried to control, cut down or stop using (first drug, etc) ?

– Q8 Injecting behaviourHave you ever used any drug by injection (non-

medical use only)?

Levels of risk – target group• Low risk (0-3)

• Abstinent or infrequent use, small amounts

• Moderate risk (4-26)• Increased regularity of use• May be some problems – relationship, health,

finance• Usual role obligations may not be fulfilled• Others may be concerned• Increase in risk taking behaviour

• High risk (27+)• Weekly/daily use• Increased desire to use• More serious health & social problems, legal,

occupational• Failed attempts to cut down• IV users

Components of Phase III trial

ASSIST score positive

Cannabis, Amphetamine, Cocaine, Opioids

Score 0-3: Information

Score 27+ or frequent IV

user: Referral to treatment

Score 4-26

Group 1: Brief Intervention

Group 2: Control Delayed

treatment

3-month follow-up: ASSIST & feedback

3-month follow-up: ASSIST & BI

Components of ASSIST BI

• F.R.A.M.E.S (Sanchez-Craig & Miller)

• Motivational Interviewing (Miller & Rollnick)

• 9 easy-to-follow steps

• 5 – 10 minutes long

• Purpose designed form to give feedback & information to clients about their risk scores

• Bolstered with take away self-help guide

Total Illicit Substance Involvement ASSIST Scores: Control vs. BI

BI n = 82

Control n = 80

p < 0.001

F (1,160) =

14.7

power = 97%

Relevance to New Zealand /Aotearoa context and mental health

• NZ has a drinking culture + many people use other substances that can adversely affect mental health (cannabis and amphetamines)

• Currently examining validity of ASSIST in Pacific peoples – then plan to do the same in Maori.

• Recently validated in clients with first episode psychosis (Hides et al, 2009, Addict Behav)

• Plan to examine feasibility and effectiveness of using ASSIST linked to brief intervention in clients with risk episode psychosis

Conclusions

• Attending to alcohol and drug misuse in the mental health sector: should it be routine practice ?

• What do you think?• ASSIST looks promising • Need to develop an appropriate intervention

that can lin with scores on the ASSIST