Harm Reduction in a Clinical Encounter: Collecting substance use history in a non-judgmental manner

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1 Testing and prevention of hepatitis C for people who inject drugs Do your patients understand the importance of hepatitis C testing and prevention? Taking an accurate and non-judgmental history of substance use, and dispensing health education and counseling in a concise and engaging manner is important to the health of patients. Incorporating hepatitis C information is especially important. How do you talk to your patients about HCV? U n d e r s ta n i n g S t i g m a Ta k i n g a s e x ua l h i s to ry Assessing for risk D e l i v e r i n g h e a lt h i n f o r m at i o n Harm Reduction in a Clinical Encounter: Collecting substance use history in a non-judgmental manner

2 introduction Harm reduction in a clinical encounter: Adapting the 4 Ps to Substance Use The standard technique for conducting sexual histories is to employ the 5 Ps, that is: Partners Practices Past History Protection (There is a 5th P, pregnancy prevention, but we won t address that here as it does not have a direct relationship to injection drug use.) By shifting around and adapting the 4 Ps, we can employ a similar model around drug-using practices and histories to help assess the risk factors and protective measures patients take when using drugs. Getting an accurate drug-use history of your patients is an important component of their care, but as we stated in another publication, it can be a difficult conversation for some patients to have due to stigma. To create a more comfortable environment and to establish trust the singular most effective way to overcome stigma in the clinical encounter remind the patient that anything discussed is protected and confidential, and normalize your questions by stating that these are things you ask of all patients. Letting the patient know that this information is essential to enable you to provide them with proper care creates a space for open discussion of substance use and risk. By establishing trust and approached with sensitivity, you can create a safe environment for your patient to openly discuss their substance use and accurately assess their risk of hepatitis C, HIV and other medical problems associated with drug use. Open-ended questions often elicit the most detailed information, but the use of some simple closed-ended questions can also provide useful answers. Keep an eye on your pace and the types of questions a mix of open- and closed-ended questions and keep them conversational and remain mindful of the stigma and shame that your patient may have experienced or continues to experience around their drug use. Recall a core principle of harm reduction: Affirms that drug users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use. You are an expert in medicine. Your patient is an expert in drug use and their life. Together, as equal partners in the clinical encounter, you can work to establish a harm reduction strategy that is meaningful and workable for your patient.

3 Harm reduction in a clinical encounter: Practices Remain mindful of stigma and explore with a non-judgmental attitude as to what kinds of drugs your patient uses and how do they use them. What substances legal or not do you currently use? How do you use them? How often do you use them? Do you use any of them together? Do you inject yourself or does someone inject you? What do you like about your current drug use? What do you dislike? Partners Assess the number of partners your patient uses drugs with. Is it a primary partner? Are there a known individuals or groups of people he/she injects with? People he/she doesn t know? Who do you inject with? I m not asking for names, but rather if you know them. Are they a regular injecting partner or are they anonymous to you? This will help me get a sense of how to best help you with good information. Do you inject yourself, or need others to do it? Do you share syringes or other injecting equipment with them? Do you know if they have hepatitis B or C or HIV? Protection The assumption that people who inject drugs are irresponsible and don t protect themselves or others from hepatitis C and other blood-borne viruses is a deeply stigmatizing belief among many. In truth, PWID often employ harm reduction and safe injection practices more often than not, and asking your patient what they do to prevent infection to themselves and/or transmission to others, is a great way to show respect and build rapport. Open-ended questions are quite applicable here, and through the course of the conversation, you will get a nice sense of how much health education and risk reduction counseling is warranted for your patient. interviewing, exploring risk An added bonus: You might learn something new about drug use and hep C prevention. People who use drugs are often the experts here, and you may learn something that you can teach to your other patients who use drugs.

4 interviewing, exploring risk Harm reduction in a clinical encounter: In addition to protection, it s also worth adding an additional P here: Perception. Awareness of hepatitis C risks can vary, and some of your patients may not be fully aware of the risk for HCV transmission. There may be knowledge of risk of HCV transmission from sharing syringes, but not from other injecting equipment. Become familiar with local syringe access sites in your area, as well as other harm reduction and drug treatment services. Read and review the patient fact sheets contained in this toolkit, talk with your patients about them and give copies to them as they leave. What do you to stay HCV negative? What do you do to prevent hepatitis C transmission to others? Do you know about naloxone to prevent drug overdose? (If your patient uses opiates or hangs out with people who do.) What programs exist in your area to help them stay negative? Are there syringe access programs in your area? Pharmacy sale of syringes? Past History Past history is applicable to both hepatitis C and history of drug use. Have they tested for hepatitis C before? Was that test confirmed positive, or did they clear the virus naturally? Have they done hepatitis C treatment in the past? If so (or even if not) do they know that pegylated interferon and its harsh side effects are a thing of the past and newer treatments are more effective, easier to take for a shorter periods of time, and have fewer side effects? This is also an opportunity to talk about hepatitis C reinfection, too. You can offer health education based off their answers. Have you ever tested for hepatitis C before? What was the result? Do you know if they confirmed your positive result? (If they say they re positive.) Have you done hepatitis C treatment before? What do you know about current treatments? For past drug use, you can explore both their drug-using history and experience with harm reduction and drug treatment. Have you tried drug treatment before? What worked? What didn t? Have you ever stopped using on your own? How did that go for you? What is your goal for your drug use? Do you want to stop entirely? Use safely? What can I do to help you achieve your goals? How can I help you here?

5 Harm reduction in a clinical encounter: Delivering health information Patients bring varying degrees of health literacy to the clinical encounter, and you will most likely have to adjust the level of complexity and detail in your delivery of health education when talking about HCV. Indeed, with the amount of misinformation that exists around HCV ( I could have sworn I was vaccinated against this, doc! ), your first appointments with a person newly diagnosed with HCV might be spent dispelling myths as you get to know your patient. Stephen Rollnick and William Miller, the founders of motivational interviewing, offer two methods of delivering health information in their book, Motivational Interviewing in Health Care: Helping Patients Change Behavior (2008). The first technique, called chunk-check-chunk, is a classic clinical technique where the provider offers a chunk of information, checks with the patient for understanding, and then offers another chunk of information, and so on. This method can create a respectful, two-way dialogue as opposed to a lecture where the patient may not feel heard or have the opportunity to convey understanding of the information under discussion. delivering inforamtion There are two methods for delivering health information: chunk-check-chunk and elicit-provide-elicit. The second technique, elicit-provide-elicit, starts by getting a sense of the patient s understanding ( elicit ), followed by you adding to or clarifying what the patient said ( provide ), and then following with other open-ended questions to elicit the patient s thoughts on the information you just provided (the next elicit ). This technique also creates a two-way dialogue, but it places the patient at the start of the conversation by asking what they know about HCV. It has the added benefit of saving you time in the clinical encounter by avoiding repeating health information that the patient already knows.

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