Assessment, Diagnosis, and Treatment Planning for Patients with OUD PDF

Assessment, Diagnosis, and Treatment Planning in Patients with OUD BY: Dr M.J.MORABBI.MD. Addiction Studies PHD  Aims: Increasing knowledge and clinical skills development in Assessment of patients with opioids use disorder...

Assessment, Diagnosis, and Treatment Planning in Patients with OUD BY: Dr M.J.MORABBI.MD. Addiction Studies PHD  Aims: Increasing knowledge and clinical skills development in Assessment of patients with opioids use disorder Diagnostic criteria for opioids use disorder Treatment planning Assessment is the process of obtaining information about the patient’s drug use and how it is affecting his or her life. It is an essential part of treatment and care for people who use drugs. before commencing the assessment, it is important to do three things : Is the patient able to complete the assessment?  Acute conditions Some patients might present in acute distress in the emergency room Usually difficult to take a good medical history, so get a prompt physical and psychiatric assessment and diagnosis. Symptom oriented treatment with continuing monitoring until Symptoms resolve. Usually, most symptoms will resolve within few hours in the emergency room setting.  Establish rapport with the patient spend a few minutes on ‘small talk’. ( Introduce yourself, and ask the patient for his or her name.) open-ended question show the patient empathy  Explain the assessment process to the patient. Assurance the patient that the assessment is confidential. Before you begin the assessment, ask the patient if he or she has any questions for you. Principles of Patient’ s Assessment Privacy Confidentiality Empathy Multidimensionality And comprehensiveness  AREAS OF ASSESSMENT Demographic characteristics Drug use history History of drug treatments High risk behaviors Physical health status Psychiatric health status Legal problems Employment Family problems  Demographic characteristics Age Gender Education level Marital status  Female patients should be asked if they are pregnant and offered the opportunity to take a pregnancy test. Substance Use History  General instructions To list common substances of use Age of initiation Years of regular substance use Days of use during last month Route of administration Amount of use in a typical day of use  Last episode of drug use Have you ever overdosed? Have you ever experienced withdrawal symptoms in the past?  Route of administration 1.oral ingestion Lower risk 2.Sniffing/snorting 3.Smoking/inhalation 4.Non IV injection 5.IV injection Higher risk Time to peak serum levels by route of administration If patient reports using a drug via more than one route write the route with highest risk and bring other routes in the comment column.  Amount of use in a typical day of use Main problematic drug of use Could be more than one drug  Risk Behaviors : High risk drug use High risk sexual behavior  High risk drug use Injecting drug use Reuse of own syringe Sharing syringes: Borrowing a syringe used by other people Lending your own syringe to others if the patient inject a drug, ask about injecting behaviours: Have you ever used a needle or syringe after some one else has used it? Do you have any infections or sores around where you inject? Have you been tested for HIV, hepatitis C or hepatitis B?  High risk sexual behavior ▪ Unprotected sexual behavior ▪ Having multiple partners ▪ Sex after using methamphetamine or other drugs (Sex drug link) ▪ Sex exchange drug or money Treatment History If the patient indicates they have previously experienced withdrawal symptoms, ask: What symptoms did you experience? What did you do or what medications did you take to relieve these symptoms? Did you experience any serious complications such as seizures or hallucinations? Do you have any concerns about your withdrawal? Physical Health  History of medical diseases Attend to any physical complaint Check history of medical disease Common medical disease according to demographic characteristics Common medical disease among people who use/inject drugs HIV/HCV/HBS testing/TSI Ask the patient if they have any history of, or currently have: Seizures or epilepsy Diabetes Heart disease Liver disease Viral hepatitis Tuberculosis Head injury Physical or intellectual disability (note type of disability) Allergies to any medications Any prescribed or over-the-counter medications they are currently taking Psychiatric Health Many people who use drugs have poor mental health. Ask the patient: Have you ever been diagnosed with schizophrenia? Have you ever been diagnosed with depression or bipolar disorder? Have you ever been diagnosed with post-traumatic stress disorder? Have you ever been diagnosed with any other mental health problem? Have you ever been given medication for a mental illness? Have you ever deliberately hurt yourself or tried to kill yourself? Do you feel like you may try to hurt or kill yourself?  Schizophernia Drug Induced psychosis Symptoms appear only during periods of Symptoms appear before heavy heavy substance use/sudden increase in substance use. potency. Symptoms persist despite drug Symptoms abate or are reduced with abstinence. drug abstinence. More likely to have a family history of Less likely to have a family history of psychotic disorders. psychotic disorders. Antipsychotics markedly improve Antipsychotics typically do not improve symptoms. symptoms. Often present with bizarre delusions, Often present with non-bizarre auditory hallucinations and/or thought delusions and/or visual hallucinations. disorder. Poorer insight into their psychosis. Better insight into their psychosis.  If there are only some symptoms rather than the full criteria, then a substance-induced etiology may be more likely. in 35 to 40 per cent of cases, it may be impossible to determine if a mood disorder is primary or substance- induced.  Co-morbid psychiatric disorders generally have greater severity of symptoms, are more resistant to treatment and have an increased relapse rate. Men use substances more often than women, making them more likely to have substance-induced psychiatric symptoms. Women using substances are more prone to an accelerated progression, or telescoping, to the development of SUD and admission to treatment with higher rates of comorbid primary psychiatric disorders, especially mood, anxiety and eating disorders.  Psychologic and psychiatric treatments History of receiving psychosocial treatments/counselling History of psychiatric visit History of admission in psychiatric ward Psychiatric medications – Lifetime – Last month The clinical assessment of persons with SUD also requires screening for non-suicidal self-injurious behavior, suicidal behavior and potential for violence/aggression. Legal, Employment and Familial Functions Diagnostic criteria for opioids use disorder From Use to Use Disorder Opioids use is commonly initiates with opium or prescription opioids (e.g., tramadol) recreationally. Recreational use escalates over time, with more frequent episodes of use, increasing amounts per episode, and changes in the route of administration to deliver faster effects (iv) Inability to control use Impairment in many areas of functioning (relationships, social function, and may develop work, housing, and legal problems  DSM 5 opioids Related Disorders Opioids Use Disorder Opioids Intoxication Opioids Withdrawal Other Opioids Induced Disorders (included in the classification of that disorder class) Depressive Anxiety Sexual dysfunction Delirium  Loss of Control taken in larger amounts or over longer period persistent desire or unsuccessful efforts to cut down or control use much time spend in activities to obtain, use, or recover from use craving, strong desire, or urge to use Social Problems failure to fulfil major obligations at work, school, or home continuing use despite persistent/recurrent social or interpersonal problems Important social, occupational, or recreational activities are given up or reduced Risky Use use in situations in which it is physically hazardous use continues despite persistent/recurrent physical or psychological problems Physiological effects tolerance withdrawal Criteria count as severity indicator Mild ( 2-3) Moderate ( 4-5) Severe ( 6-11) Treatment Planning  Patient’s motivation and readiness for treatment Patient's experience with different treatment methods Patient’s understanding and expectation from treatment  Developing a treatment plan involves reviewing the patient’s assessment and consulting with the patient as necessary. The patient has the right to be involved in making decisions about what treatment he or she receives, and involving the patient can help to improve patient cooperation with treatment.  The treatment plan should be developed using the stepped care approach. Stepped care involves matching treatment to patients based on the least intensive intervention that is expected to be effective. Based on how the patient responds to the chosen intervention, the healthcare worker can increase (‘step up’) or reduce (‘step down’) the intensity of treatment. Once a treatment plan has been commenced, it is important to regularly evaluate the patient’s progress and determine if the interventions that were used have been useful to the patient.  Stages of change Precontemplation Contemplation Preparation Action Maintenance Relapse  Precontemplation Does not see themselves as having a problem although others might identify the problem. No intention of changing the problem and don’t want to hear about it. Desire to change the people around them Often seen as resistant or “in denial” I don’t have a problem  Contemplation Recognizes that there is some reason for concern. Seesaws between reasons to change and reasons to stay the same. Is best pictured by a scale, you’ve the argument to change your position and the argument to stay at your position and they almost in equal balance.  Continue….. Characterized by ambivalence – both considers and rejects change Stuck The but stage Indefinite plan to change in next 6 months Can spends years here Fear of failure I have a problem, but ………..  Preparation Plan to change in the next month. Small changes may actually be happening here. I’m making a plan to resolve my problem. rather than diving in headfirst they usually just test the waters.  Action person is engaging in particular actions to bring about change. Visible change happens. It’s usually very difficult. I’m working on it and it’s very difficult.  Relapse A reversion back to problem behavior. Any movement backwards through the cycle. Usually involves going back to contemplation. Not necessarily a bad thing.(reevaluate and make small changes in quit plan) Is to be expected(Behavior Changing take many tries to succeed) I messed up and ……  Important points: 1. Stage of change constantly is changing. 2. Pushing forward will result in resistance. 3. People are in different stages for different issues. Precontemplation about opium use Contemplation about Methamphetamine use Preparation about cigarette smoking