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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Drug and alcohol medicine

Definition

Drug and alcohol medicine in general practice potentially covers all drug and substance use disorders.

There are significant areas of overlap with mental health, as comorbidity is common among substance users.

Pain management and addiction issues, as well as doctor's health, tobacco and gambling problems, are also part of this field.

Curriculum in practice

The following case illustrates how the drug and alcohol medicine curriculum applies to general practice:

  • Mandy, 29 years of age, was on a methadone program for 4 years, but was discharged when she kept intermittently using heroin. She has not been receiving regular care for several months. She arrives today late in the afternoon asking to be fitted in as she is feeling very unwell. She is shivering and has a low grade fever with a heart rate of 95 bpm. Her main complaint is abdominal cramps and you note she also has dilated pupils and a runny nose. Although initially polite, she is asking for codeine for the pain and the longer you take to examine her, the more agitated and angry she becomes. She says the pain is so bad that she may as well go and kill herself as her life is worthless anyway. She also says that if you would just help her she is ready to turn her life around.

Rationale and general practice context

Australia is a drug-using society. National household surveys demonstrate that alcohol is consumed by the majority of the population and that cannabis is the most commonly used illicit drug.1

Two legal drugs – alcohol and tobacco, are the two greatest causes of preventable disease and death in this country. These causes include lung cancer, ischaemic heart disease and chronic obstructive pulmonary disease from tobacco – while alcohol contributes to various cancers, alcoholic liver cirrhosis and road injuries.

The role of GPs in drug and alcohol medicine

General practitioners are increasingly being asked by government and public health authorities to become more involved in the diagnosis and management of drug and alcohol problems in their patients.

General practitioners need a range of medical and psychological skills when managing drug and alcohol problems, as these substances can affect a wide range of physical and mental functions, which directly impact on successful management.

Many GPs resist taking on this role.2 3 4 This may stem from lack of confidence and skills in the area, and a belief that intervention is doomed to failure. Other perceived barriers are lack of time, difficulties in raising the topic during the consultation, and having a negative attitude toward individuals with alcohol and other drug problems. Yet the results of interventions by GPs can be very significant.5 Brief interventions for alcohol abuse and opiate pharmacotherapies for heroin addiction are two common examples of effective GP initiated treatments, proven by multiple studies in Australia and overseas.

General practice is well positioned to manage substance use disorders and the degree to which a particular GP will manage these conditions will depend on the level of skills they possess.

The maintenance of clear professional roles and boundaries is a key principle in the management of drug and alcohol conditions in the general practice setting. Doctors may also need to treat and support drug-using colleagues and need to be aware of specific related treatment issues. Some drugs used for the treatment of alcohol and drug disorders are governed by strict legislative prescribing requirements, which practitioners need to work within.

Drug and alcohol problems are a major public health burden, and GPs are also in an ideal position to help reduce drug related morbidity and mortality.

The management of drug and alcohol conditions requires a multidisciplinary approach to patient management, often in conjunction with other medical and social service agencies. General practitioners need to know where and when to refer patients, and clinicians working in communities with a high rate of substance use disorders may consider incorporating more specialised skills into their everyday work, and this may involve further training in drug and alcohol medicine as required.

Related curriculum areas

Refer also to the curriculum statements:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

PDRUT1.1

Use nonjudgmental and empathic communication when taking a drug and alcohol history.

PDRUT1.2

Effectively engage a patient who has a substance use disorder.

PDRUT1.3

Communicate effectively and appropriately with significant others (eg. the family of person with a substance use disorder).

PDRUT1.4

Discuss common terms and quantities (eg. standard drinks of alcohol and other common drugs used in our community).

PDRUT1.5

Understand what constitutes harmful alcohol and other drug use.

PDRUT1.6

Understand the reasons people have for using drugs.

PDRUT1.7

Apply harm reduction principles, especially in relation to the medical interview.

PDRUT1.8

Use motivational interviewing skills and assess readiness to change.

PDRUT1.9

Providing objective health information on drugs to the patient, and also to community groups if required.

PDRUT1.10

Develop appropriate boundaries in managing the patient's problems, that take into account medicolegal responsibilities, limits of confidentiality and a respectful, therapeutic relationship.

PDRUT1.11

Be aware of risks of inappropriate behaviour when dealing with patients who are socially stigmatised and who may have boundary problems; they can be needy and manipulative at times.

PDRUT1.12

Develop a long lasting therapeutic relationship for managing the range of chronic medical and behavioural issues in the addiction lifecycle.

2. Applied professional knowledge and skills

PDRUT2.1

Take a nonjudgmental medical history and perform physical examination relevant to the presenting drug and alcohol problem.

PDRUT2.2

Intervene early in substance use disorders.

PDRUT2.3

Be familiar with the management of the main drugs of abuse in the Australian community.

PDRUT2.4

Manage adolescent drug problems with affected persons and their parents, especially regarding cannabis, alcohol and psychostimulants.

PDRUT2.5

Safely prescribe medications for dealing with drug withdrawal from alcohol, heroin, cannabis and amphetamines, according to skill level.

PDRUT2.6

Assess and advise on comorbidities including hepatitis B and C, and HIV.

PDRUT2.7

Manage common co-existing psychiatric conditions, including personality disorders and how they interact with substance abuse issues.

PDRUT2.8

Manage drug seeking behaviour.

PDRUT2.9

Apply the principles of management of substance use disorders to addictions (eg. gambling).

PDRUT2.10

Assess patients with chronic pain and opiate dependence.

3. Population health and the context of general practice

PDRUT3.1

Identify drug and alcohol conditions in practice patients.

PDRUT3.2

Identify those at high risk of drug and alcohol problems.

PDRUT3.3

Detect and, where appropriate, manage mental illness in all patients with drug and alcohol problems.

PDRUT3.4

Manage drug and alcohol disorders in conjunction with carers, families (including children) and the local community.

PDRUT3.5

Manage drug and alcohol problems in patient subpopulations (eg. people from Aboriginal and Torres Strait Islander backgrounds; people from culturally and linguistically diverse backgrounds; and men, women and young people).

PDRUT3.6

Manage, where appropriate, the treatment of drug dependent colleagues, including issues of medical board involvement.

4. Professional and ethical role

PDRUT4.1

Understand and practise appropriate confidentiality, including confidentiality issues with a minor (and breaching this), including mandatory notification if needed.

PDRUT4.2

Display nonjudgmental attitudes when managing drug and alcohol conditions.

PDRUT4.3

Outline common responses in the health professional when caring for patients with mental illness and strategies for self care.

PDRUT4.4

Manage common drug and alcohol presentations, intoxication and withdrawal in a nonjudgmental and safe manner.

PDRUT4.5

Assess patient capacity and competency for making decisions when they are intoxicated.

PDRUT4.6

Maintain appropriate professional boundaries with patients who have drug or alcohol problems.

PDRUT4.7

Maintain professional boundaries and behaviours when managing health professionals with drug dependence.

PDRUT4.8

Where appropriate, participate in peer support activities directed at self care and support for colleagues.

PDRUT4.9

Understand prescribing and reporting requirements for drugs of misuse, including illegal and prescription drugs (including opiates and benzodiazepines).

PDRUT4.10

Regularly update knowledge of drug and alcohol legislation and policies that apply to local jurisdictions.

5. Organisational and legal dimensions

PDRUT5.1

Practice confidentiality and consent in the practice setting and the circumstances in which these processes may be modified.

PDRUT5.2

Be familiar with drug and alcohol legislation and policies that apply to local practice context.

PDRUT5.3

Work as part of a multidisciplinary team for drug and alcohol treatment.

PDRUT5.4

Work in conjunction with available local drug and alcohol medical and counselling services (eg. drug withdrawal services, forensic services, local psychiatric services, and drug and alcohol physicians) and demonstrate ability to collaborate with these).

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

PDRULM1.1

Demonstrate how to take a drug and alcohol history in a nonjudgmental manner.

PDRULM1.2

Demonstrate how to establish rapport and empathy with patients who present with an alcohol or other drug problem.

PDRULM1.3

Describe an interview style that is empathic and incorporates reflective listening.

PDRULM1.4

Describe common terms and quantities (eg. standard drinks of alcohol and other common drugs used in our community).

PDRULM1.5

Describe and discuss some of the reasons people have for using drugs.

PDRULM1.6

Demonstrate how harm reduction principles can be incorporated into the medical interview when dealing with alcohol and other drug problems.

2. Applied professional knowledge and skills

PDRULM2.1

Demonstrate how to take a medical history and perform a physical examination relevant to the presenting drug and alcohol problem.

PDRULM2.2

Demonstrate a nonjudgmental attitude when taking a history and adopting a treatment plan.

PDRULM2.3

Describe the main drugs of abuse in the Australian community.

PDRULM2.4

Outline the main treatments available for common drug and alcohol problems.

PDRULM2.5

Describe the pharmacological and pathophysiological effects of commonly abused drugs.

3. Population health and the context of general practice

PDRULM3.1

Consider the possibility of mental illness in all drug and alcohol patients because alcohol, tetrahydrocannibol, amphetamine, volatile substances and opiate classes are all major contributors to morbidity and mortality.

4. Professional and ethical role

PDRULM4.1

Describe how confidentiality issues may relate to personal and family situations.

PDRULM4.2

Display a nonjudgmental approach to drug and alcohol medicine.

PDRULM4.3

Describe issues of the vulnerability of health professionals to becoming drug dependent.

PDRULM4.4

Outline common responses in the health professional when caring for patients with mental illness and discuss strategies for self care.

PDRULM4.5

Describe the professional responsibilities and the legislative requirements of the prescription of drugs, including drugs of dependence, and the potential for misuse.

5. Organisational and legal dimensions

PDRULM5.1

Outline the principles of confidentiality and consent in the practice setting and the circumstances in which these processes may be modified.

Prevocational doctor

1. Communication skills and patient-doctor relationship

PDRULP1.1

Demonstrate effective engagement with a patient who has a substance use disorder.

PDRULP1.2

Describe the fine line between acceptance of the patient and indulgence toward the consequences of unacceptable behaviour.

PDRULP1.3

Describe hazardous alcohol and other drug use from the history and examination.

PDRULP1.4

Demonstrate skills in encouraging safer drug use before dependence occurs (eg. An early intervention phase).

PDRULP1.5

Communicate effectively and appropriately with significant others (eg. family of person with substance use disorder).

PDRULP1.6

Demonstrate ability to provide objective health information on drugs to the patient, and also to community groups if required.

2. Applied professional knowledge and skills

PDRULP2.1

Demonstrate how to take a medical history and perform a physical examination relevant to the presenting drug and alcohol problem.

PDRULP2.2

Demonstrate a nonjudgmental attitude when taking a history and adopting a treatment plan.

PDRULP2.3

Describe the main drugs of abuse in the Australian community.

PDRULP2.4

Outline the main treatments available for common drug and alcohol problems.

PDRULP2.5

Describe the pharmacological and pathophysiological effects of commonly abused drugs.

3. Population health and the context of general practice

PDRULP3.1

Demonstrate the ability to discuss confidentiality issues with the patient and issues regarding doctor responsibility, to both the patient and the community, regarding their drug use.

PDRULP3.2

Identify those at high risk of drug and alcohol problems in the hospital setting and utilise strategies to screen for mental health disorders.

PDRULP3.3

Discuss the diagnosis and management of mental health disorders with the carers and family of patients with a drug and alcohol condition.

PDRULP3.4

Identify sources of support for carers and families of patients with mental illness.

4. Professional and ethical role

PDRULP4.1

Demonstrate management of common drug and alcohol presentations, intoxication and withdrawal in a nonjudgmental but safe manner.

PDRULP4.2

Demonstrate ability to assess patient capacity and competency for making decisions when the patient is intoxicated.

PDRULP4.3

Demonstrate maintenance of appropriate professional boundaries with patients who have drug or alcohol problems.

PDRULP4.4

Describe professional responsibilities regarding drugs of dependence

5. Organisational and legal dimensions

PDRULP5.1

Describe the process for referring patients with drug and alcohol conditions in the hospital setting.

PDRULP5.2

Be aware of legislative requirements when treating a drug dependent patient.

Vocational registrar

1. Communication skills and patient-doctor relationship

DRULV1.1

Demonstrate development of appropriate boundaries in managing the patient's problems, which take into account medicolegal responsibilities, limits of confidentiality and a respectful therapeutic relationship.

DRULV1.2

Be aware of risks of inappropriate behaviour when dealing with patients who are socially stigmatised and who may have boundary problems; they can be needy and manipulative at times.

DRULV1.3

Demonstrate ability to recognise drug seeking behaviour and have strategies to deal with this behaviour in the clinic.

DRULV1.4

Demonstrate how to negotiate a management plan with the patient that delineates the roles and responsibilities of the patient (and the doctor).

2. Applied professional knowledge and skills

PDRULV2.1

Demonstrate ability, where appropriate, to safely prescribe medications for dealing with drug withdrawal from alcohol, heroin, cannabis and amphetamines.

PDRULV2.2

Demonstrate ability to discuss adolescent drug problems with affected persons and their parents, especially regarding cannabis, alcohol and psychostimulants.

PDRULV2.3

Demonstrate ability to assess and advise on comorbidities including hepatitis B and C and HIV.

PDRULV2.4

Describe common co-existing psychiatric conditions, including personality disorders and how they interact with substance abuse issues.

PDRULV2.5

Outline methadone and buprenorphine programs and their roles in managing opiate dependence.

PDRULV2.6

Describe the biopsychosocial consequences of lifestyle disorganisation that may occur as a result of drug use, and demonstrate an ability to conceptualise a plan to deal with this.

PDRULV2.7

Describe how these management principles apply to other addictions, including gambling.

3. Population health and the context of general practice

PDRULV3.1

Implement screening for alcohol and drug use in at risk populations.

PDRULV3.2

Describe the drug and alcohol issues of patient subpopulations (eg. people from Aboriginal and Torres Strait Islander backgrounds, people from culturally and linguistically diverse backgrounds, and men, women and young people).

PDRULV3.3

Recognise and address the needs of carers, siblings and children of those with drug use disorders.

4. Professional and ethical role

PDRULV4.1

Demonstrate a range of consulting skills, including the ability to refuse unreasonable requests and setting limits for patients.

PDRULV4.2

Demonstrate ability to develop a management plan for patients with drug dependency.

PDRULV4.3

Describe and, where appropriate, demonstrate basic drug and alcohol counselling and describe when presentations require more intensive management in a drug and alcohol unit.

PDRULV4.4

Detail professional and legislative requirements of the community based prescribing of drugs of dependence, including opiates and benzodiazepines.

5. Organisational and legal dimensions

PDRULV5.1

Describe state based regulations regarding the prescribing of drugs of dependence and notifications of persons with drug dependence.

Continuing professional development

1. Communication skills and patient-doctor relationship

PDRULC1.1

Demonstrate motivational interviewing skills and assess readiness to change.

PDRULC1.2

Demonstrate the ability to develop a long lasting therapeutic relationship for managing the range of chronic medical and behavioural issues in the addiction lifecycle.

2. Applied professional knowledge and skills

PDRULC2.1

Demonstrate, where appropriate, training and experience in prescribing opiate substitution pharmacotherapy.

PDRULC2.2

Demonstrate the ability to process the assessment of minors who abuse alcohol or other drugs.

PDRULC2.3

Demonstrate competence in assessing patients with chronic pain and opiate dependence.

PDRULC2.4

Review knowledge requirements for drug affected populations within local community and practice populations.

3. Population health and the context of general practice

PDRULC3.1

Seek out opportunities for further training in the mental healthcare of patients from diverse backgrounds, according to local need.

PDRULC3.2

Develop skills in assessing and managing the impaired drug dependent doctor.

PDRULC3.3

Demonstrate ability to provide advice and professional support to a colleague affected by substance abuse problems (often done in conjunction with a designated doctor's health program).

PDRULC3.4

Participate in quality assurance activities of the effectiveness of local mental health promotion and disease prevention (eg. clinical audit).

4. Professional and ethical role

PDRULC4.1

Demonstrate participation in peer support activities directed at self care and support for colleagues.

PDRULC4.2

Ensure participation in a peer review or support group of practitioners who also deal in this area.

PDRULC4.3

Describe treatment approaches if encountering a drug dependent colleague or supervisor including the duty to involve the medical board if concerned about the wellbeing of the doctor or their patients.

PDRULC4.4

Outline legal issues for managing minors with drug or alcohol problems.

PDRULC4.5

Demonstrate ability to discuss confidentiality issues with a minor and also explain reasons for breaching this, including mandatory notification if needed.

PDRULC4.6

Regularly update knowledge of drug and alcohol legislation and policies that apply to the local practice context.

5. Organisational and legal dimensions

PDRULC5.1

Demonstrate the ability to work as part of a multidisciplinary team.

PDRULC5.2

Describe available local support services (eg. drug withdrawal services, forensic services, local psychiatric services, and drug and alcohol physicians) and demonstrate ability to work collaboratively with them.

PDRULC5.3

Detail staff safety practice measures in place for dealing with alcohol and drug affected individuals.

References

  1. Australian Institute on Health and Welfare. 2010 National Drug Strategy Household Survey report. Canberra: Australian Institute of Health and Welfare; 2011.
  2. Anderson P, Kaner E, Wutzke S, et al. Attitudes and managing alcohol problems in general practice: an interaction analysis based on findings from a WHO collaborative study. Alcohol and alcoholism 2004;39(4):351–6.
  3. Scarborough J, Eliott J, Braunack-Mayer A. Opioid substitution therapy – a study of GP participation in prescribing. Aust Fam Physician 2011;40(4):241–5.
  4. Jacka D, Clode D, Patterson S, et al. Attitudes and practices of general practitioners training to work with drug using patients. Drug Alcohol Rev 1999;18(3):287–91.
  5. Roche A, Freeman T. Brief interventions: good in theory but weak in practice. Drug Alcohol Rev 2004;23(1):11–8.

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