Addictions - The Royal New Zealand College of General Practitioners

Addictions
GPEP Syllabus
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Addictions
Addictions
Addiction is wide-ranging and can include
alcohol, tobacco, recreational and prescription
drugs, other substance misuse, problem
gambling and other gaming, sexual addiction,
obsessive shopping, eating disorders, obesity
and social networking. Some of these may be
increasingly fuelled by ease of access to the
internet. Harmful effects on individuals and
families may be compounded by co-dependent
or dysfunctionally enabling behaviour by family
members and health professionals.
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Addictions

The general practitioner (GP) should be competent in
recognising signs or symptoms of addiction, including codependency.
Family history is becoming increasingly evident
as a factor in addiction, so using whānau ora 1 principles and
concepts is essential if we are to break the cycle of addiction
within families.
Māori are twice as likely to smoke tobacco compared to
non-Māori, with the highest prevalence of smoking being
in Māori women .2 Māori are also more likely to be regular
cannabis smokers, and to have started smoking cannabis
when aged less than 14 years. While non-Māori are more
likely to consume alcohol, Māori are more likely to drink
at a hazardous level. 3
Addictions in the context of general practice
Jonelle is a 30-year-old mother of four. She presents with
fatigue and low mood. She is working two jobs to boost
the family income but there is never enough money. She
cannot afford a phone at the moment, and the electricity
was cut off last week. Her partner’s job is ‘on and off’.
Later in the day Elizabeth, an elderly patient with
severe arthritis, comes to see you for a repeat script
of her sleeping pills and pain relief. It is not yet time to
prescribe. She initially tells you that she lost them but
on further questioning she advises you that she thinks
her son-in-law has stolen them. You are aware that her
son-in-law is the driver of the school bus which takes
your children to and from school each day.
Misuse of prescription drugs is of particular concern as most
are obtained from GPs; doctors themselves are especially
at risk and should be wary of prescribing for colleagues or
patients who are unknown to them.
The learning outcomes and expectations listed here will be
undertaken over the three years of training in no particular
order but at every opportunity that presents itself.
1
Ministry of Health. 2002. He Korowai Oranga – Maori Health Strategy – http://www Maorihealth.govt.nz
2
Ministry of Health. 2006. Tatau kahukura: Maori health chart book.
3
Ministry of Health. 2006. Tatau kahukura: Maori health chart book.
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Addictions
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Addictions
Communication
Clinical Expertise
Domain 1: Communication
Throughout vocational training a registrar will develop a
variety of competencies and be expected to:
• take a comprehensive drug and alcohol history
Domain 2: Clinical Expertise
Throughout vocational training a registrar will develop a
variety of competencies and be expected to:
• discuss the different recreational drugs and their effects
• communicate with people in a non-judgemental but
steadfast manner
• discuss managing alcohol or drug detoxification and
the risks associated with it
• effectively manage and communicate with an angry
patient, developing skills to diffuse volatile situations
• use motivational interviewing skills to assess people with
addictions and to guide management
• communicate effectively, where appropriate, with
family/whānau when managing an addicted
family member
• recognise signs of drug intoxication and manage
the situation effectively with appropriate follow-up
and referral
• explain how to deal with patients who may need scripts
for what are potentially addictive drugs
• become familiar with using AUDIT or other screening
tools and be able to discuss the results with their patients
• perform a brief intervention
• communicate effectively with other agencies involved in
drug and alcohol care and addictions
• be alert to the possibility of problem gambling and
explore this with the patient.
• describe medications used in treating addictions and
their side effects
• understand and describe the requirements for safe
prescribing of controlled drugs
• describe the various support agencies available for all
forms of addiction
• recognise signs that may suggest addictive behaviour
and its impact on family/whānau.
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Addictions

Professionalism
Scholarship
Domain 3: Professionalism
Throughout vocational training a registrar will develop a
variety of competencies and be expected to:
• maintain appropriate relationships and communication
with colleagues and allied health professionals involved in
addiction and drug misuse
• demonstrate commitment to patient safety, as well as
community safety, and act accordingly
• make valid and timely decisions about treatment, referral
and follow-up, recognising their own abilities, limitations
and resources
• recognise own risk of drug or alcohol misuse or other
addictive behaviour and have strategies in place to
reduce/address this risk (eg. collegial support, own GP,
clinical supervision).
Domain 4: Scholarship
Throughout vocational training a registrar will develop a
variety of competencies and be expected to:
• construct a vignette or MATCH question on one of
the following:
– fetal alcohol syndrome
– evidence base for brief interventions
– motivational interviewing
– alcoholic liver disease
– methamphetamine
– cannabis
– synthetic cannabis
– ‘party pills’
– magic mushrooms
– solvent abuse
– diet pills
– opiates
– benzodiazepines
– problem gambling
– the role of whakawhanaungatanga in the treatment
of Māori with addiction.
• demonstrate commitment to personal professional
development and plan accordingly
• demonstrate competence in accessing and applying
current evidence in relation to best practice.
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Addictions
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Addictions
Context of
General Practice
Management
Domain 5: Context of General Practice
Throughout vocational training a registrar will develop a
variety of competencies and be expected to:
• reflect on the practice population and implications for risk
of addiction and the burden of disease
Domain 6: Management
Throughout vocational training a registrar will develop a
variety of competencies and be expected to:
• describe systems in place to keep controlled drugs (CD)
and CD prescription pads secure
• establish relationships with providers managing longterm
addictions, for example Alcoholics Anonymous,
Narcotics Anonymous, mental health and addiction
services, Problem Gambling Foundation
• describe the local addiction treatment services and
community support groups
• ensure the safety of themselves, staff and patients when
dealing with aggressive patients
• develop practice protocols for managing addicted or
drug-seeking patients.
• reflect on equity of access to health care for addiction
and work to reduce disparities, particularly for specific
populations/geographic areas eg. remote/rural areas
• participate in national health targets and quality initiatives
relating to addictions
• be familiar with the local process for sharing information
regarding drug seekers (eg. phone tree) and utilise it
appropriately.
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Addictions

Learning experiences
and assessment
Year 1 Learning experiences Assessment
In practice
Seminar day
Clinical attachments
• Minimum five patients per half day
• After hours
• Dealing with drug-seekers
One-on-one teaching
Role play of difficult cases – drug-seeker, addicted,
alcoholic, problem gambler
Discussion of addiction presentations
Video/direct observation – teacher to registrar, registrar
to teacher
Practice team meetings (participation as able)
Community visits
• Pharmacy
• Smokefree services
• Māori providers
• Drug and alcohol team
• Detox ward in hospital
• Alcoholics Anonymous and Narcotics Anonymous and
other local services.
In practice visit from a medical educator
• Direct observation
• Record review
• Personal reflection
Specialist presentation
Small group learning
• Case-based discussion
• Role play
• Video interview
• Journal club and discussions
• Articles on Māori health inequalities
Registrar presentation of:
• Vignettes on list above, plus prescription addiction,
resources such as local detox, smoking cessation,
Alcoholics Anonymous and how they work
• MATCH quizzes
• WEBS – research on addiction-related topics
In-practice visits
Video/direct observation
Vignettes
WEBS
MATCH questions
Patient satisfaction survey
Skills log
Online quiz
Learning record
Summative
• GPEP written
• GPEP clinical
• Academic output
Further details about academic
output in Year 2
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Addictions
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Addictions
Year 2 Learning experiences Assessment
In practice
Learning group
Other learning
As for Year 1, plus:
• Increase in patient numbers seen daily
• Log book of cases seen or discussed in small groups
related to addiction, e.g. smoking
• Attention to PHO performance parameters for addiction
• Practice team meetings and input into these
Audit
Medical educator visits
• Video/observation
• Case discussion
• Record review
Involvement in CORNERSTONE ® accreditation if occurs
Significant event review
Establishing relationships with providers of drug and
alcohol services
Case-based discussion
Role play
Literature review and critical appraisal
High-level cognitive processes
Specialist or guest speaker
NZRC resuscitation course minimum level 5
and appropriate for practice environment
(dealing with acutely toxic patients)
CME
Professional development plan
Collegial support – case discussion
Academic output
• Enhanced audit
• Research
• University paper
Medical educator visits
NZRC resuscitation course
Audit project
Professional development plan
Mini CEX
Collegial support
eLearning modules
Patient satisfaction survey
Summative
• GPEP written
• GPEP clinical
• Academic output
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Addictions

Year 3+ Learning experiences Assessment
Clinical
Educational
As for Year 2, plus:
Training under vocational scopes – if applicable
Be able to discuss management protocols for drugseekers
and people actively seeking help for their
addictions with reference to local providers and
personal relationships developed with them
Management of drug and alcohol presentations in:
• Outpatient clinics
• Community-based services
Work with allied health professionals involved in
drug and alcohol services:
• Pharmacy
• Alcoholics Anonymous
• Detox ward
• Social worker
• Multidisciplinary team meetings
Investigation of drug and alcohol-related conditions
• Examination skills relating to chronic alcohol abuse
and methamphetamine use
• Detoxification in-patient services
• Outpatient services
• One-on-one teaching
• Departmental teaching
• Journal clubs
• Peer groups
Medical educator visits
Audit
Academic output
Mini CEX
Learning log
Supervisor reports
Multi-source feedback
Previous summative assessments
if not completed
Fellowship Assessment
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Addictions
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Addictions
References/resources
• careNZ www.carenz.co.nz
• Alcohol and Drug Association of New Zealand
www.adanz.org.nz
• Mental health and addiction in older people www.health.govt.
nz/publication/mental-health-and-addiction-services-olderpeople-and-dementia-services
• Alcohol and drug helpline www.alcoholdrughelp.org.nz
• Problem Gambling www.pgfnz.org.nz
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Addictions

978-1-927240-17-5
© The Royal New Zealand College of General Practitioners, New Zealand, 2012
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December 2013