LEARNING OUTCOMES
      Identification of possible barriers to disclosure about 
      substance misuse
      Recognition of effective ways of facilitating dialogue about 
      substance misuse
      Appreciation of responding to patient cues
      Use all available opportunities to ask about substance 
      misuse
      Communicate effectively when administering screening and 
      assessment tools
      Understanding the principles of motivational interviewing 
      techniques
     INTRODUCTION – distinctive 
     features 
       Presenting problems may be directly or indirectly (falls, fits, confusion) 
       related to substance use 
       Substance use can be difficult to uncover
       The history taking needs to take these issues into account 
       Patients have varying needs so professionals need a range of skills and 
       techniques to respond to these different situations
       Patients may be:
       Embarrassed, frightened, defiant, cautious, secretive, aggressive, angry, 
       suspicious, in denial
       May not wish to discuss these issues in the presence of family
       Consider substance use a lifestyle choice and no business of a 
       professional 
     DISTINCTIVE FEATURES 
      Questions need to be asked appropriately 
      Sensitivity, awareness and practice can improve communication 
       techniques 
      Patients may need reassurance about confidentiality and privacy 
      Keep an open mind and resist assumptions about race, religion 
       and sexuality 
      Students and patients need to realise that in some situations it is 
       not possible to guarantee confidentiality eg child protection or 
       safeguarding vulnerable adults
      Screening tools need to be introduced in a sensitive and 
       sympathetic manner
     BARRIERS
      Patients may feel 
      Apprehensive about divulging information about substance 
       misuse, and the impact this has on their life style
      Fear being judged 
      Fear being stereotyped
      That you do not have patience or time, or are distracted
      Patients may tell staff what they think they want to hear
      Open ended questions are more likely to yield more 
       information
      ASSESSMENT (CROSS REFERENCE)
       All psychiatric assessments should routinely include systematic substance 
        use enquiry which should be empathic, non judgemental and non 
        confronational
       Psychiatric disorders may lead to substance misuse, and substance misuse 
        may lead to psychiatric symptoms 
       Acute intoxication, withdrawal and chronic regular use of substances may 
        present with psychological symptoms
       Mental state and physical examinations, investigations (urinary drug screen, 
        breathalyser) and collateral information should be gathered and interpreted 
        in the context of substance use
       Consider possible life threatening conditions eg delirium tremens, overdose, 
        severe withdrawal, Wernicke Encephalopathy   which need emergency 
        responses