New recreational drugs and the primary care approach to patients who use them

BMJ 2012;344:e288
Clinical Review

New recreational drugs and the primary care approach to patients who use them

Winstock AR, Mitcheson L

Correspondence to: A R Winstock adam.winstock@slam.nhs.uk

[EXCERPTS]

Approaching the question of drug use in primary care

Brief screening procedure for possible users of new recreational drugs

  • Question 1: €œHave you used any drugs in the following list in the past year, such as . . . cocaine, cannabis, ecstasy? €
  • If yes to any, go to question 2
  • Question 2: €œHave you used any other substances, such as GHB, ketamine, or newer drugs such as mephedrone in the last year? €
  • If yes to any, go to question 3
  • Question 3: €œWhich of those drugs have you used most recently? €
  • Go to question 4
  • Question 4: €œHow often would you take this [or them]? €
  • Go to question 5
  • Question 5: €œHave you noticed any link between the problems you are having and your use of these? €

Clinical presentations directly related to drug use could occur in one of two ways. The patient might have clear concerns about their drug use or have a problem that they think is a consequence of drug use (for example, withdrawal on cessation of GBL). Alternatively, the patient might report a problem that could be drug related, but is not recognised as such (for example, urinary symptoms related to ketamine use).

In both scenarios, as with other lifestyle behaviours that can be difficult to discuss, we recommend a guiding communication style based on motivational interviewing. A good starting point is to assume that the patient might be ambivalent about change. The key to motivational interviewing is to ascertain the patient €™s concerns and respond accordingly; hold back from advocating change until a clearer picture is obtained. This strategy encourages the patient to actively participate in the consultation and favours a positive change in behaviour. Box 2 outlines a recommended approach if the problem of substance use is not immediately apparent but seems pertinent to exclude.

Box 2: Recommended approach to exploring problems related to substance use

  • Ask what the patient wants to talk about first: €œWhat would you like to talk about today? €
  • Introduce the idea of a substance use assessment and invite the patient to accept it: €œI usually ask people about their drug and alcohol use €”would it be ok if we can cover that today as well? €
  • Negotiate time and priorities
  • For problems likely to be related to substance use, consider talking about substance use generally rather than telling the patient that you think their problem is directly attributable at this stage:
  • €œOften when people are feeling like you do today I like to rule out substance use as a contributing factor €”would it be ok if we spend some time with me asking some questions about this? €
  • €œI have seen some patients in which this problem is related to drug or alcohol use €”is it ok to explore this with you now? €

Seek the patient €™s permission before asking questions about substance use ( €œis it ok for me to ask you some questions about your GBL use? €); if permission is given, a reminder of the limits of confidentiality might still be needed. In cases where family members have raised concerns about a patient, doctors should explore the relative €™s concerns, the impact on them, and their coping, with signposting to relevant additional support if appropriate.

What is the approach to assessing patients who admit to problems related to drug use?

A good assessment should capture the key information outlined in table 4 [link to free full-text PDF], and allow the patient to actively contribute. Open ended questions can achieve this aim as well as obtain relevant information ( €œTell me about your drug use? €, €œWhat is your drug use over a typical week? €). Asking the patient to explain drug jargon and effects can also help to build rapport. During the assessment, use open questions to elicit and explore the patient €™s potential concerns ( €œWhat concerns do you have? €, €œYou said that you experience discomfort on urination €”how might that be related to your drug use? €).

Simply providing feedback with specific reference to concerns the patient has identified can help the patient think about their drug use and its consequences in a new way. At this stage, substance use might still be ruled out as a problem, or the patient might deny any problems related to their drug use. If this scenario occurs, end the discussion by seeking permission to review the situation at a later date.

Any further questioning could begin with a simple open question: €œWhere would you like to go with this next? € If the patient does not know, invite them to consider that your medical expertise may help them; for example, ask: €œIs there anything I can specifically help with? € This step could involve further information about the presenting problem or drug use, harm reduction advice, guidance about changing or reducing substance use, managing physical or psychiatric problems, or referring the patient to a specialist service.

If the patient clearly attributes an identified problem to drug use, they will probably begin to ask questions or be receptive to expert information (tables 1-3 and 5 provide substance specific information). A set of principles applies to the exchange of information at this stage, which follows the circular process of eliciting the patient €™s interest ( €œWould you like to know a bit more about how mephedrone can affect your mood? €), providing information ( €œWhen people use stimulants over a weekend and don €™t get any sleep, it can lead to a reduction in the chemicals in your brain that help keep our mood stable and feeling happy €), and eliciting the patient €™s response to that information ( €œHow does that fit with your experience? €).

These principles of information exchange also apply to the provision of harm reduction information and exploration of risk behaviours related to drug use, such as sex. This stage of the consultation could lead to a discussion about a possible change in substance use. Do not assume that the patient wants to change or even needs expert help to change. To introduce the idea of change, ask an open question: €œWe €™ve spoken about some of the concerns you have and how your drug use might be related to this €”where do we go from here? € A direct question might be: €œWould you like to do something about your drug use? €

If the patient indicates that they wish to change, ask them how they might do this and whether they think they need professional support. If the patient does not know what they should do, this stage might be an opportunity to provide harm reduction advice. Since little is known about these substances, guidance on harm reduction is usually limited to common sense advice, including limiting consumption, reviewing the progression of any health concerns with a period of cessation, and total avoidance of the drug for people in high risk groups, such as those with pre-existing mental health issues. For patients who seek information on internet forums about a drug before procuring it, remind them that although online reports can be useful, they can also be unreliable or irrelevant to a particular substance. Irrespective of whether the patient expresses an interest in change, end the consultation by asking for permission to review the issue in the future.

Are psychological interventions and specialist referral needed?

The benefits of a single session of motivational interviewing in addressing substance misuse by young people are supported by findings from a cluster randomised trial, with effect sizes ranging from 0.34 for alcohol to 0.75 for cannabis. The same study showed that this approach can be used to target use of several different substances in a generic fashion. Substance specific interventions have shown broader positive effects, for example, on mood and on the use of other substances, as shown by a randomised controlled trial of cognitive behavioural therapy in amfetamine dependence. Most users of new recreational drugs will be intermittent temporary users and will not experience any serious harms. We recommend a staged approach to management that begins in the primary care setting with the type of brief intervention outlined in this article. If a clinical problem or accompanying mental health problem is identified and the patient does not respond to a brief motivational intervention, consider referral to a specialist service for substance misuse if the patient is willing. Monitoring the association between drug use, cessation, and the progression of physical and mental health symptoms over time will help to inform the need for specialist referral.

[Link to free British Medical Journal article for full review of common drugs, tables, and references]

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