Assessment and Diagnosis 1 Assessment forms the first

Assessment and Diagnosis 1

Assessment forms the first point of contact for the counsellor with the client Assessment and Diagnosis 2

Assessment: Benefits Screening Establish Rapport Diagnosis Motivation enhancement Planning management Referral Assessment and Diagnosis 3

Stages of assessment n Assessment is not a one-time phenomenon Assessment and Diagnosis 4

Assessment – tools n Clinical: n n Investigations n n Through history and examination Performing certain tests Instruments n Use of standard tools/questionnaire for assessment Assessment and Diagnosis 5

Clinical assessment n Means of clinical assessment n Interaction with patient / client n Interaction with family member / companion n Examination n Previous treatment records Assessment and Diagnosis 6

Clinical Assessment – History n Socio-demographic profile n n n n Name Age Sex Marital status Qualification Occupation Type of family Place of residence Assessment and Diagnosis 7

Clinical Assessment – History Details of drug use n n n Type of drug currently being used: the class of the drug (e. g. opioid) and the particular chemical composition (e. g. buprenorphine); in case the chemical composition is not understood, the local name used should be noted Frequency and amount of drug currently used Mode of use of the drug currently used Last dose of drug used Assessment and Diagnosis 8

Clinical Assessment – History Complications associated with drug use n Physical: health hazards associated with IDU n n Local: redness/swelling at injecting site, wounds, sores, blocked veins, etc. Systemic: hepatitis, lung diseases (e. g. chronic bronchitis), etc. n Legal: n n n involvement in illegal activities to obtain drugs (e. g. thefts, pick pocketing) Arrests/detainment by police Charges under NDPS act for drug using/dealing Driving under intoxication with drugs Physical fights under intoxication of drugs Assessment and Diagnosis 9

Clinical Assessment – History Complications associated with drug use n Occupational – financial n n n n Inability to work productively Accidents at workplace Frequent absenteeism Loss of job Frequent change of job Loss of income, Debts Assessment and Diagnosis Psychological n n n Guilt & shame Anxiety Depression 10

Clinical Assessment – History Complications associated with drug use n Marital/Familial/social n n n n Fights with family Neglect of household responsibility Physical violence Outcast from family Separation/divorce Homelessness Stigmatisation in society Assessment and Diagnosis 11

Clinical Assessment – History High risk behaviors Injection Related Sex Related Assessment and Diagnosis 12

Clinical Assessment – History n Injecting related risk behaviors: n n n n Sharing of needles Sharing of syringes, cotton, vials, or other paraphernalia Cleaning practices Sites of injection use iv/im; any dangerous sites of use Reuse of needles and syringes Places where injections are taken Needle site complications Assessment and Diagnosis 13

Clinical Assessment – History n Sex related risk behaviors: n n n n Sexual intercourse without condoms Multiple sexual partners Sexual intercourse with female sex workers Anal intercourse Sex with a person who has STIs Sex under the influence of drugs/alcohol Sex work for procuring drugs Assessment and Diagnosis 14

Clinical Assessment – History n HIV related knowledge and beliefs n Knowledge on HIV n n n n What is HIV? How is HIV transmitted? Name the 4 modes of transmission of HIV What is the difference between HIV and AIDS? What happens when one is infected with HIV? Does one gets HIV by touching and kissing? Does one gets HIV by sharing food of others? Can HIV be cured? Can HIV be prevented? How? Ask open ended questions Assessment and Diagnosis 15

Clinical Assessment – History n History of referrals sought, esp. n n ICTC, STI clinic, Detoxification and other drug treatment services, Tuberculosis centre Assessment and Diagnosis 16

Clinical Assessment – History n n n History of any medical illness & details History of any mental illness & details Current living arrangements Social support Motivation level Assessment and Diagnosis 17

Clinical Assessment – Examination n Evidence of drug use with respect to n n Intoxication Withdrawals Route of drug use Evidence of physical damage due to drug use n Systemic examination Assessment and Diagnosis 18

Assessment - Investigations n Two types n To assess the degree of physical damage n n Hemogram, Liver function test, Renal function test, HIV, Hep B & C To confirm the presence / absence of drugs in the body n Screening of body fluids, most commonly urine Assessment and Diagnosis 19

Assessment – Instruments n n n Structured set of questions to assess an individual Act to validate assessment across time, place and person Examples n n n Addiction Severity Index Clinical Opiate withdrawal scale CAGE Assessment and Diagnosis 20

Diagnosis n Diagnosis should include the following: n n n Primary drug status Secondary drug status Physical co-morbidity Psychological morbidity Psychosocial issues Assessment and Diagnosis 21

Diagnosis n Drug status: Drug use syndromes n n n Abuse/Misuse Dependence Intoxication Assessment and Diagnosis 22

Diagnosis n Drug status: Drug use syndromes n n n Dependence Abuse/Harmful use Intoxication Assessment and Diagnosis 23

Diagnosis of drug dependence n Definition “A cluster of physiological, behavioural and cognitive phenomenon in which use of a substance or class of substance takes on a much higher priority for an individual than other behaviours…. . ” n Three or more criteria to be present for some time in a one-year period. Assessment and Diagnosis 24

Diagnosis of drug dependence: Criteria 1. Tolerance: n n Need for increasing the amount of substance consumed to achieve intoxication or the desired effect Markedly diminished effect with continued use of the same amount of substance Example A person ‘X’ started with one line of heroin smoking to get intoxicated; with time, he had to increase the dose to 1 pudiya per day to get the same amount of intoxication n A person ‘Y’ started with one peg of whisky and got high; with continued use, has to now consume 3 pegs of whisky to get the same high Assessment and Diagnosis 25

Diagnosis of drug dependence: Criteria 2. Withdrawals n n Set of symptoms experienced on stopping or reducing the amount of the substance after prolonged use Every class of substance (e. g. alcohol, opioids, etc. ) has its own unique set of withdrawal symptoms Assessment and Diagnosis 26

Diagnosis of drug dependence: Criteria n n E. g. opioid withdrawal Early symptoms n n n n n Anxiety Restlessness Yawning Nausea Sweating Running nose Running eyes Dilated pupils Abdominal cramps n Delayed symptoms n n n n Assessment and Diagnosis Severe Anxiety Restlessness Diarrhea Vomiting Muscular spasm, pain Chills Increased heart rate, blood pressure Increased temperature 27

Diagnosis of drug dependence: Criteria n n n E. g. Alcohol withdrawal Anxiety Restlessness Increased heart rate Increased breathing Shaking (tremors) of hands and other body parts n Sweating Sleeplessness Inability to concentrate n Delirium tremens n Confusion; disorientation to time, place and person; visual hallucinations; illusions; delusions Seizures / fits n n n Assessment and Diagnosis 28

Diagnosis of drug dependence: Criteria 3. Impaired control of behaviour associated with substance use in terms of its starting the use of the substance, stopping the use of the substance, or controlling the level of use n Example A person ‘X’ had thought that he would consume only 1 peg of alcohol on a given day, but he is not able to stop after 1 peg, but continues to take more than peg: loss of control A person ‘Y’ planned to stop his drug use, but is unable to do so: loss of control Assessment and Diagnosis 29

Diagnosis of drug dependence: Criteria 4. Preoccupation with the use of substance: manifested as: n n n Great amount of time spent in using the substance/procuring the substance/recovering from the effect of the substance Other activities which were pleasurable are given up as a result of the substance use Other interests/hobbies given up due to indulgence in substance use Assessment and Diagnosis 30

Diagnosis of drug dependence: Criteria 5. 6. Continuing use of the particular substance despite harmful consequence of the substance on the individual Strong desire to use the substance: Craving n Craving can be spontaneous or in reaction to certain stimulus (e. g. place where the individual takes drugs, drug using friends, shop where the individual purchases drugs/alcohol, etc. ). The craving in reaction to stimulus is called as ‘cue induced’ craving. Assessment and Diagnosis 31

Diagnosis n Drug status: Drug use syndromes n n n Dependence Abuse/Harmful use Intoxication Assessment and Diagnosis 32

Drug abuse/harmful use n Harmful use: A pattern of use of substance, in which there is evidence of damage to the health of the individual n n n The damage can be physical or mental health damage Abuse: used in the USA system n A pattern of substance use, in which there is damage to legal, social and occupational spheres of the individual’s life, in addition to the physical sphere. Assessment and Diagnosis 33

Diagnosis n Drug status: Drug use syndromes n n n Dependence Abuse/Harmful use Intoxication Assessment and Diagnosis 34

Opioid intoxication Mental/Behavioural effects n n n n Drowsiness Initial euphoria (happiness) Dysphoria (irritable mood) Impaired judgement Impaired performance Agitation or retardation Impaired attention Hallucinations Physical n n n Assessment and Diagnosis Slurred speech Slow respiration Slow pulse Stupor/coma Pupillary constriction Pupillary dilation (anoxic) 35

Alcohol intoxication Mental/Behavioural effects n n n n n Drowsiness Impaired attention Impaired judgement Impulsive behaviour Inappropriate sexual behaviour Aggression Impaired performance Easy irritability or happiness Stupor / coma Physical n n n n Flushed face Headache Rapid pulse Sweating Slurred speech Motor in-coordination Unsteady gait Respiratory depression Assessment and Diagnosis 36

For successful assessment n n Assessment is a skill, and improves with practice For successful outcome of an assessment: n n n Establish rapport with the client Have non-judgemental attitude Effective communication Patient listening Maintain and reassure confidentiality of the response Inform the client about the benefits of carrying out detailed assessment Assessment and Diagnosis 37

Time for Role play …. . Assessment and Diagnosis 38