Assessment & Management

Assessment is the process of defining the nature of the problem due to psychoactive substance use, determining a diagnosis, and developing specific management recommendations for addressing the problem or diagnosis. The purpose of assessment is to gather the detailed information needed for a management plan that meets the individual needs of the person. The assessment leads to the formulation of a diagnosis which, in turn, guides the management.

Assessment

The assessment includes-

History taking

Gather information that is clinically relevant and is likely to contribute to the diagnosis and management plan. Also, it offers an opportunity to establish rapport. A comprehensive history can take some time to obtain and may require more than one session.

Information should be gathered from multiple sources including-

What to ask?

  • Socio- demographic details

  • Presenting problems and reasons for seeking treatment

  • Details of substance use including substance use history timeline (including age started using, first problems, use pattern, type of substance, quantity, frequency, route of use)

  • Any behaviours associated with substance use that may risk the person’s health and the health of others (where, when and with whom substance consumption typically occurs, what triggers substance consumption, activities when intoxicated, financial implications, capacity to care for children, and violence towards others)

  • Commencement and development of substance use in relation to other life events, for example, by taking a chronological history

  • Features of harmful use/ dependence

  • Social networks and the person’s substance consumption patterns

  • Current situation (accommodation, living arrangements, relationships, children, social support, work/study, legal issues, other agencies involved in care)

  • Risk assessment for self-harm/ suicide, aggression and violence

  • Adverse consequences due to substance use

  • Details of high risk behavior (injecting use, high risk sexual behavior)

  • Details of past abstinent attempts

  • Details of past treatment sought

  • Past medical and surgical history

  • Conditions that may contraindicate use of certain medications

  • Family history

  • Personal history

  • Premorbid personality

Clinical examination

What to look for?

  • Signs of intoxication

  • Signs of withdrawals

  • Signs of route of substance use (needle marks etc.)

  • Physical complications

  • Physical/ psychiatric comorbidity

  • Conditions that may contraindicate use of certain medications

Laboratory investigations

Which investigations?

  • Guided by the clinical assessment

  • Common investigations include-

    • complete haemogram

    • blood sugar levels

    • serum electrolytes

    • liver function test

    • renal function test

  • Investigations for other possible causes of clinical presentation and co-occurring medical conditions (viral markers, Tuberculosis, etc.)

Assessment is not a one-time event. Rather it is a process that continues throughout the management. The focus, intensity and modality can vary depending on the stage and phase of management.

Diagnosis

International Classification of Diseases and Related Health Conditions (ICD)- 10 has specified diagnostic criteria for acute intoxication, withdrawal state, harmful use and dependence syndrome.

Acute intoxication

A transient condition following the administration of a psychoactive substance, resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses.

This should be a main diagnosis only in cases where intoxication occurs without more persistent substance- related problems being concomitantly present.

Some of the clinical features of acute intoxication of various categories of psychoactive substances are given below-

Click on the tabs below to read about the clinical features of acute intoxication of various categories of psychoactive substances.

Withdrawal state

A group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of alcohol after repeated, and usually prolonged and/or high-dose, use of alcohol. The withdrawal state may be complicated by convulsions.

Some of the clinical features of withdrawal state of various categories of psychoactive substances are given below-

Click on the tabs below to read about the clinical features of withdrawal state of various categories of psychoactive substances.

Harmful use

A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (e.g. as in cases of hepatitis from the self-administration of injected drugs) or mental (e.g. episodes of depressive disorder secondary to consumption of a substance). The diagnosis requires that actual damage should have been caused to the mental or physical health of the user.

Dependence syndrome

A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:

  • a strong desire or sense of compulsion to take a substance

  • difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use

  • a physiological withdrawal state when substance use has ceased or been reduced, as evidenced by the characteristic withdrawal syndrome for the substance, or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms

  • evidence of tolerance, such that increased doses of the substance are required in order to achieve effects originally produced by lower doses

  • progressive neglect of alternative pleasures or interests because of substance use, increased amount of time necessary to obtain or take alcohol or to recover from its effects

  • persisting with alcohol use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm

Read more about these diagnostic criteria here.

Management

The Mental Health Gap Action Programme intervention guide (mhGAP-IG) for mental, neurological and substance use disorders has been developed by the World Health Organization. The mhGAP Intervention Guide has been developed to facilitate mhGAP-related delivery of evidence-based interventions in non-specialized health-care settings. It provides the full range of recommendations to facilitate high quality care at first- and second-level facilities by the non-specialist health-care providers in resource-poor settings. It presents integrated management of priority conditions using protocols for clinical decision-making.

Management of Acute Intoxication

Watch the video below on management of acute intoxication.

Management of Withdrawal State

Watch the video below on management of withdrawal state.

Management of Harmful Use

Watch the video below on management of harmful use.

Management of Dependence Syndrome

Watch the video below on management of dependence syndrome.

Pharmacological interventions for management of opioid intoxication (overdose), withdrawal and prevention of relapse in opioid dependence

Click on the buttons below to read about these medications.

Mutual help groups

Watch the video on mutual help groups.

Carer support

Watch the video on carer support.

Populations with specific needs

Working with adolescents

Watch the video on working with adolescents.

Working with women who are of child-bearing age, pregnant, or breastfeeding

Watch the video on working with women who are of child-bearing age, pregnant, or breastfeeding.

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