Assessment can inform effective care planning to support young people and those involved in their care throughout the withdrawal process.
The Purpose of Assessment
The purpose of assessment in relation to withdrawal care is to:
- Establish rapport with the young person and set the foundations for continuing care
- Provide the young person with information about withdrawal care, treatment options and post-withdrawal support
- Clarify the young person’s goals in relation to their substance use
- Gain necessary information about the young person, e.g. support people, legal / child protection issues, previous treatment experiences, mental health issues.
- Identify any potential risks that may arise during withdrawal care as a result of physical withdrawal or psychosocial issues (e.g. self-injury)
- Clarify the preferences and specific requirements of the young person so as to plan the most suitable withdrawal option (adapted from Kenny et al, 2009)
Comprehensive assessment is enhanced by respectful engagement and clear communication. Where a young person and those involved in their care participate in decision-making processes regarding their care prior to and during withdrawal their motivation and commitment is enhanced.
Key components of an Assessment for Withdrawal Care
Nature and extent of the young person substance use
Christie & Temperton (2008) suggest that young people who have been using substances on a daily basis for six weeks or longer are more likely to have a level of dependence and therefore experience withdrawal symptoms
A significant dependence on alcohol will generally take approximately six months to develop. A significant dependence on cannabis, opiates and amphetamines can take as little as one month
- A clear information exchange between the young person and the clinician, respecting the young person’s choice as well as clinical judgement
- A detailed description of the young person’s rights and responsibilities and access to grievance procedures
- A clear explanation of protocols regarding confidentiality, including concerns regarding harm to themselves and/or others
- Establishing the withdrawal care relationship between the young person and the clinician
Risk factors (bio-psychosocial)
- A substance use history detailing daily quantity and frequency of use including the young person’s account of potency, route of administration, length of time used, changes in pattern of use, all other substances tried in the past, polydrug use
- Underlying co-occurring physical and mental health conditions
- Suicide risk assessment
- Self injury assessment
- Domestic/family violence
- Child protection issues
- Identifying psychosocial factors that may present barriers to achieving the young person’s goals
- Young person’s goals of withdrawal
- Service setting matching
- Pre-admission planning to identify opportunities for support and intervention where withdrawal care is not immediately possible
- Establishing an appropriate withdrawal plan with the young person including management of withdrawal syndrome, potential triggers for anxiety, self-injury, anger etc and coping strategies
- Establishing an appropriate exit plan that ensures the young person’s safety
- Identifying linkages that could offer post-withdrawal support (Adapted from Kenny et al., 2009)
Anxiety about an upcoming withdrawal process can be reduced by providing information and education together with reassurance and supportive counselling. Anecdotal information is also useful. Using relevant case examples that demonstrate to the young person that withdrawal is possible can prepare them and make the process may seem more ‘real’ and achievable. After the assessment, when the young people has had time to think about the process they may have further questions. This highlights the importance of offering an open invitation to a young person or those involved in their care for further contact to seek clarification.
Assessment should be conducted continuously during the withdrawal process.
Objective withdrawal scales
Objective Withdrawal Scales (OWS) can be used by nurses and practitioners who have been trained to measure of the severity of withdrawal symptoms. These tools may be used at initial assessment and/or for ongoing monitoring to assess the young person’s response to medication.
Alcohol withdrawal, the objective alcohol withdrawal scales are usually used every four hours to titrate the Diazepam dose.
The Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) is a tool used to scale symptom severity for simple alcohol withdrawal, and complicating factors such as co-occurring disorders and polydrug use may impact on the appropriateness of its use. The ten-item scale can be used to evaluate the presence and severity of withdrawal symptoms, with higher scores indicating increased risk for severe withdrawal.
Scoring on the Withdrawal Assessment of Alcohol (CIWA-Ar) correlates directly with the severity of withdrawal, that is, the higher the score, the more severe the withdrawal symptoms. It is recommended that staff using the Withdrawal Assessment of Alcohol (CIWA-Ar) receive appropriate training, as incorrect scoring will result in increased benzodiazepine dosing.
Objective benzodiazepine withdrawal scales are used four times a day to monitor the withdrawal and ensure the correct rate of reduction of medication.
Withdrawal from benzodiazepines may be monitored using the Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ) (Tyrer et al., 1990). The BWSQ is a 20-item self-report, validated questionnaire (Couvee & Zitman, 2002).
Objective opiate withdrawal scales can be used to monitor withdrawal and also assess the correct dose of Methadone, Suboxone or Buprenorphine. The Objective Opiate Withdrawal Scale (OOWS) is recommended for use (Kenny et al, 2009).
Note: Withdrawal scales should not be solely relied upon to monitor complicated withdrawal as they may lack the sensitivity to detect progression to serious illness. Withdrawal monitoring should always include close clinical observation and judgement. (Kenny et al, 2009)
Subjective withdrawal scales
Subjective Withdrawal Scales (SOWS) are also used to gain an understanding about the young person’s experience of withdrawal. These scales can be completed each day by the young person and they provide an opportunity practitioners to discuss the results with the young person and offer more tailored support during the withdrawal. Young people undertaking a home-based or outpatient withdrawal can use the SOWS throughout the day to identify and times and circumstances that result in increased symptoms. This can then be discussed with a practitioner and/or support people and coping strategies can be devised and further support arranged if necessary.
Withdrawal scales are also available for cannabis (Appendix 11) and amphetamines (Appendix 10) in the Turning Point AOD Withdrawal Guidelines (Kenny et al, 2009).