Prepared by J. Mabbutt & C. Maynard NaMO September 2008

1: Principles and Communication Prepared byJ. Mabbutt & C. MaynardNaMO September 2008

1: Principles & Communication:Objectives During the session the key principles of communication in the drug and alcohol field will be outlined, with a focus on special population groups A brief description of the important issues of poly drug use & harm minimisation will also be covered By the end of the session, nurses and midwives will have a better understanding of the background and policy directive relating to these guidelines By the end of the session, nurses and midwives will have a better understanding and sensitivity of these key issues and the needs of special population groups

1: Prevalence • Drug and alcohol use is common and affects individuals, families and communities in all sections of society • 23,313 deaths in 1998 in Australia were attributed to drug use (National Drug Strategy Household Survey, 1999). Of these: • 19,019 deaths were associated with tobacco use • 3271 deaths related to alcohol use with alcohol being the main cause of deaths on Australian roads • 1023 deaths resulted from illicit drug use • Estimated annual health and economic cost is $34.4 billion

1: Prevalence • Over 260,000 hospital separations between 1996-97 were attributable to drug and alcohol use • 40% of ED presentations and 30% of hospital admissions are attributable to alcohol use • 50% of D&A consultation and liaison activity is attributable to alcohol (Connigrave et al 1991) • Less than one third of nurses identify alcohol disorders (Foy and Kay)

1: Policy Directive 1 NSW Health Policy, 2007 – “Nursing and Midwifery Management of Drug and Alcohol Issues in the Delivery of Health Care” states minimum standards of practice Role of managers to: • adopt nursing and midwifery management of D&A issues within their unit(s) as a high priority • ensure awareness and implementation of Guidelines • ensure adequate levels of education • monitor delivery and quality of management & education of D&A issues

1: Policy Directive 2 Roles of nurses and midwives include: • awareness, understanding and implementation of the guidelines, policies and protocols • routine D&A assessment and recognition of management issues from assessment information • knowledge of effects of D&A dependence & psychosocial impacts • recognition of intoxication, overdose, withdrawal and implementation of initial management strategies • provision of relevant patient education and specialist referral • participation in professional development on D&A issues

1: Principles and Communication (1) Focus on giving an equal regard to the physical, psychosocial and cultural wellbeing of all patients: including comprehensive assessment, interventions and harm reduction strategies for those at risk All episodes of care offer a critical moment for intervention: includes offering information, providing education & assessment for interventions Access to comprehensive health care is every individual’s right

1: Principles and Communication (2) A client-centered approach is needed to effectively care for patients with D&A problems and when appropriate family and significant others should be involved Health professionals & services have a responsibility to effectively manage and support each person presenting with substance related problem

1: Polydrug use • Increasing use of more than one drug over the last couple of decades • Use of just one drug is becoming rarer • Medication, over the counter drugs, naturopathic, homeopathic, legal and illicit drugs could potentially interact • Poly drug use should be considered when assessing someone’s substance use

1: Principles and communicationHarm minimisation • Seeks to reduce the harms associated with drug and alcohol use to the individual and the community • Abstinence is one of a range of strategies and not the only goal • Public health approach • Offers patients a range of treatment options aimed at minimising harm

1: Harm minimisation strategies beneficial • Providing clean injecting equipment – disposal units, needles, syringes, swabs • Providing access to drug and alcohol withdrawal services & rehabilitation services • Introducing legislative measures – restricting tobacco advertising • Health promotion campaigns – preventing young people taking up smoking, risks of drink spiking in pubs and clubs, promoting light beer • Methadone (opioids), Acamprosate (alcohol) and NRT (nicotine)

1: Principle and Communication Effective, clear, non-judgmental communication assists in building rapport & developing a sense of trust This is the key to undertaking a quality assessment, understanding the person’s major issues, & managing drug & alcohol-related problems Primary service providers, nurses & midwives often provide the link between the person, other members of the multidisciplinary team, the person’s family, & other service providers

1: General Principles Communication (1) • Drug & alcohol use is a health issue not a moral issue • A person’s substance use history should be taken as part of the routine clinical assessment • Confidentiality from family members and/or significant others should be considered • Cultural & linguistic diversity can make communication difficult, so consider the assistance of culturally appropriate interpreters (including Aboriginal interpreters)

1: General Principles Communication (2) • Be clear and straightforward about who you are, your role, what your are asking about and why • Attend to the person’s immediate concerns before addressing sensitive issues that may be unimportant to the person • Build rapport and a sense of trust by listening to what the person wants, why they may be worried, and what they believe will help them • Show your concern about the person’s drug & alcohol use problems without prejudice

1: Improving cross-cultural communication • Different cultural groups may misinterpret your requests for information or have different expectation of the service • Responding requires flexibility in approach and creativity that services are appropriate for the person and family • Complying with rigid guidelines maybe inappropriate • This flexibility will foster rapport and a greater willingness for the person to participate and cooperate

1: Improving cross-cultural communication: some suggestions (1) • Always use approved interpreter services • Always follow the guidelines for how to use interpreter services • Allow sufficient time to interpret the situation from the person’s and their family’s cultural perspective • Provide ongoing evaluation of assessment and care

1: Improving cross-cultural communication: some suggestions (2) • Be clear, concrete and specific • Respond with respect, immediacy and timeliness • Be sensitive to embarrassment • Examine your own expectations

1: Co-existing mental health disorders and substance misuse (1) • People with a mental illness are at an increased risk of developing problematic drug or alcohol use • 30 to 80% of patients in mental health settings have drug use issues • More than 50% of people who use substances have experienced psychiatric symptoms • The prevalence of people with co-existing mental health and drug use problems may be increasing

1: Co-existing mental health disorders and substance misuse (2) • These co-existing disorders are associated with: • increased symptoms and suicide behaviours • greater non compliance with treatment • more hostile and aggressive behaviours • increased risk of violence to others • higher rates of offending, imprisonment and homelessness • longer psychiatric admissions

1: Aboriginal and Torres Strait Islander people and communities (1) • The use of substances is affected by the environment, access, their history, social situations and personal choice • More Aboriginal and Torres Strait Islanders abstain from drinking • Of those who consume alcohol, 48.7% of Aboriginal and Torres Strait Islanders are at risk of long term alcohol related harm vs 9.7% non-Indigenous • 25% of Aboriginal people over 15 reported having recently used an illicit substance • Nursing staff need to be respectful, sensitive and flexible as with any patients • A thorough non-judgmental assessment is still the key

1: Aboriginal and Torres Strait Islander people and communities (2) Specific factors/hints for communication are: DO • Be polite, respectful, and treat the person as equal to yourself • Enlist the help of your health facility’s Aboriginal and Torres Strait Islander health liaison worker • Be very careful about non-verbal signals – use a friendly tone of voice, smile; take some time to show your interest in the patient and their family or other visitors

1: Aboriginal and Torres Strait Islander people and communities (3) Specific factors/hints for communication are: DO • Ensure privacy when talking about substance issues • Be aware that separation from family can be very frightening for Aboriginal and Torres Strait Islander people • Try to accommodate the patient’s wishes for a relative or other trusted person to be with them if they wish for it

1: Aboriginal and Torres Strait Islander people and communities (4) Specific factors/hints for communication are: DON’T • Don’t assume anything. Do not base your responses to a patient on any assumptions about their illness, their Aboriginality or their behaviour. • Don’t use stereotypes. Relying on stereotypes (e.g. ‘Aborigines all have drinking problems’) is not only offensive but dangerous – it can lead to other health problems being ignored or misdiagnosed

1: Aboriginal and Torres Strait Islander people and communities (5) Specific factors/hints for communication are: DON’T • Don’t be pushy or confrontational when giving health advice • Don’t give the impression that you are too busy to talk to the patient properly • Aboriginal and Torres Strait Islander people often say they wish professionals would get to know them a little: “I wanted to ask questions of the doctors and I was frightened… You walk in and they say ‘What’s wrong with you?’ instead of talking to you.” (Eckerman et al, 1995)

1: Sexual and gender diverse groups • National and international research into Lesbian Gay Bisexual & Transgender (LGBT) health highlights a strong relationship between homophobia, heterosexism, social exclusion & the health status of individuals • The percentages of same-sex attracted young people injecting drugs dropped from 11% in 1998 to 4% in 2004 • Nevertheless, drug use still remains substantially higher than for heterosexual young people, for example, double the number of same-sex attracted young people have injected drugs

1: Ageing population • The Australian community is increasing in age therefore recognition of their needs is necessary • Drug and alcohol use in this population need more support as their age and effects of the use make them less able to cope in the community • Studies showed that 72% of men and 54% of women over 75 drank alcohol – 11% of men and 6% female drank at harmful levels • 50% of the adult indigenous population are current daily smokers (2004)

1: People from diverse cultural and linguistic backgrounds • Drug use can have different meanings with a range a diversity in patterns of use in different cultural groups • For example, Europeans are more likely to use alcohol and cannabis than those from Asian or Arabic backgrounds • People from cultural and linguistically diverse backgrounds were less likely to drink alcohol, in the last week, 44.5%, compared to 56.5% in the wider community

1: Rural communities • Rural NSW has higher rate of harmful drinking in males, in 14-19 yr olds and a higher rate of road fatalities • Rural and remote populations face specific challenges in providing comprehensive health care • Challenges include distance, travelling times, availability of clinicians, the dispersal of the population • These factor effect the delivery of integrated Drug and Alcohol services • Telecommunications and the use of technologies can have a special role in the delivery of services to these populations

1: Children in development stages (1) • Alcohol consumed by mothers can seriously affect the health anddevelopment of their unborn child • Some babies will be born with foetal alcohol spectrum disorder (FASD) and may be/have: • Be small at birth • Developmental disabilities • Behavioural and learning problems • Abnormalities in the appearance and shape of the face • Eye problems and heart problems

1: Children in development stages (2) • FASD is more prevalent in Aboriginal & Torres Strait Islander than non-Indigenous infants • For further information, refer to the National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. (March 2006)http://www.health.nsw.gov.au/pubs/2006/ncg_druguse.html • NSW Health Neonatal Abstinence Syndrome (NAS) Guidelines, 2005focus on care of opioid dependant women and care of the newborn from a child protection perspective http://www.health.nsw.gov.au/policies/pd/2005/PD2005_494.html

1: Young people with emerging problems • Many young people do not use drugs and alcohol at dangerously high levels, but there are harms associated with all levels of misuse • Some young people will develop chronic patterns of drug use and engage in frequent harmful binge use • Recent tobacco and cannabis use has almost halved in the last 20 years • In 2002, 69% of NSW secondary school students reported drinking in the last year and 45% reported in the last 4 weeks • 40% of 16 to 17 year olds binge drink at least occasionally

Prepared by J. Mabbutt & C. Maynard NaMO September 2008