Substance use history taking report

Mr. A is a 68 years old Caucasian man who lives in a residential home. He was admitted to the ward two weeks before mainly for problematic alcohol use and plan is to detoxify him. Mr. A is known to psychiatric services for 20 years and he was diagnosed as Korsakoff’s psychosis, central pontine myelinosis and recurrent depression secondary to alcohol abuse. According to Mr. A, he had several admissions to the hospital due to alcohol problem. He used to live alone and was not able to care for him so was placed in present residential home. Currently his problems are related to alcohol use.

According to staff at this residential home, Mr. A was drinking everyday , non-compliant to his medications, trying to steal things from other residents rooms and was also caught by police couple of times, for shoplifting. He was also encouraging fellow residents to drink alcohol into the home. The staffs was finding it very difficult to manage him, hence this admission was planned. Since his admission to the ward he is under care of multidisciplinary team. He is on alcohol detoxification regimen for severe alcohol dependence. He has been prescribed Tab.

Chlordizepoxide 20mg QID. He is on Mirtazepine 30mg nocte, temazepam 20mg nocte, folic acid 5mg mone and thiamine 100mg mone. He is also being prescribed spironolactone 2. 5mg and senna 2tabs nocte. He is attending to recreational therapies with occupational therapists and motivational counselling with psychotherapist. Initially he was non-compliant to treatment and absconded from ward but later, on persuasion he is co-operating with team. Drug and alcohol history Current drug use: Tobacco- alcohol: Mr. A agrees smoking 5-6 cigarettes per day but denies use of alcohol.

Since his admission in ward he is smoking nearly 15 cigarettes a day. According to the residential home staff, though he denies, staff found alcohol from his room and has been drinking everyday and appears dependent on alcohol. However he accepts excessive use in past and said he was abstinent for 7 years. He restarted drinking 5 years ago but its not regular use. At one occasion he absconded from ward and on return appeared drunk but he denied it. He reports smoking 35-40 cigarettes a day in past. Prescribed medication: Mr. A is on mirtazepine 30mg nocte.

He has been on this medication for his depression from 5years. He is also being prescribed temazepam 20mg nocte for insomnia. He states sometimes he used to take more than prescribed dosage. He is currently on vitamin supplements like folic acid 5mg mone and thiamine 100mg mone. He is also being prescribed spironolactone 2. 5mg and senna for constipation. He says that he is compliant to his medication but staff at residential home denies this. He is put on detoxification regimen. He is being prescribed chlordizepoxide 20mg qid. Method of self injection:

Mr. A reports he has never injected and has no intention of injecting. He states he is scared of needles and injections. Consequences and complications of drug use: Mr. A states that he never experienced any difficulty related to alcohol, however he reported an accident when he was heavily drunk and had multiple fractures. He had jaundice five years ago and his reports shows severe liver cirrhosis. He has central pontine myelinosis and Korsakoff’s psychosis secondary to alcohol abuse. He states he had depression but is not related to alcohol.

He presented delusions of grandeur where he claims to be a billionaire and having series of BMW cars. He claims having a licence to fly plane, drive a tractor and have apartments all over the world including America, Spain and Thailand. He said he agreed to get admitted just because he wants to prove people wrong. He reported that he started having problems in his relationship with his wife and his drinking increased. It further worsened which resulted in divorce. He states his daughter and son are anti-smokers and anti-drinkers so he is not drinking or smoking in house.

He says his children are against him, so left him in residential home. He was involved in a business of car dealing and he was doing well before he started drinking. He states he lost his business as he was occupied with drinking. He spent all his money for alcohol. He claims when he did not have money he started borrowing from friends and selling his goods, car, clothes etc. later when he was unable to make he tried to steal things from shops. He denies any police case but there are evidences when he was caught by police couple of times.

Though alcohol consumption is permitted in residential home, he states, he sometimes manages to drink. Due to this he has problems with residential home staff and his placement in home. Contact with drug treatment agencies: Mr. A was involved with ECDAS (Enfield centre for drug and alcohol services) which was not successful as he was not motivated and continued to drink. History of drug and alcohol use: Mr. A is currently smoking 15 cigarettes a day. He started smoking at the age of 33years. He used to smoke occasionally but later increased to 35-40 cigarettes per day.

He smokes alone and states started smoking as a fun. He says he enjoys smoking and has no problem so continued to smoke. Since his admission his smoking is restricted to 15 cigarettes a day. Mr. A currently denies use of alcohol but accepts drinking occasionally. Since his admission to the hospital, he is not drinking but there was an incident where he absconded from ward and on return was smelling alcohol and brought a box of ledger with him. He states that he started drinking at the age of 38 years. He was frustrated due to his disputed relationship with wife and was unable to cope so started drinking.

He claims he was drinking 3-4 cans of beers everyday. Later on he started drinking 1 bottle of brandy or gin. His states his drinking further increased to 2-3bottles per day and he used to drink up to 4 bottles on weekends. He reports that he had no difficulty with alcohol use and he used to feel relax and calm after drinking. According to Mr. A, his drinking worsened and eventually leads to his divorce. He stopped drinking on his own, without any difficulty, at age of 55, and was abstinent for 7 years. He restarted drinking 5 years ago. He states he never experienced any withdrawals.

He is being prescribed temazepam 20mg nocte and states he sometimes used to take more than prescribed dosage when feel restless. He tried cannabis twice before, but due to financial problem and he did not find it interesting he stopped its use. Client’s own perception on drug use: He believes smoking is not a problem and finds it pleasurable, so does not intend to quit smoking. According to Mr. A, he has no problem with drinking alcohol. He states that he enjoys drinking and never had any difficulty due to this. As he stopped drinking alcohol for 7 years, he states it is not difficult for him to quit.

However he believes that he is drinking occasionally and he does not want to stop it. I believe he is on pre-contemplation stage. Summary and interpretation of severity of main substance use Mr. A relates his alcohol drinking with his social problem of his stressful relationship with his wife and inability to cope with it. He has been drinking alcohol for 35 years. He accepts he break up with his wife and lost his business due to excessive use of alcohol. He is having problem with staff and his placement at residential home he is currently living in.

He is suffering from Korsakoff’s psychosis, central pontine myelinosis and recurrent depression secondary to alcohol abuse. He has lack of insight and poor motivation. He does not accept any difficulty due to use of alcohol. As previously he had a period of abstinent of about 7 years, and he has potential he can be motivated to stop drinking. He needs therapeutic counselling to improve motivation. Recommendation on what type of care/ treatment would be most appropriate for client to be offered in relation to his substance use

Building therapeutic relationship and allow client to ventilate his feelings would be helpful. As Mr. A is not accepting his alcohol use, it would be better to refer him to psychologist and help him to develop an insight into his problem of alcohol dependence. Under the care of multi-disciplinary team he is on detoxification for alcohol. Information on craving, withdrawals, and coping strategies would be beneficial. Reassure him of withdrawal symptoms and coping skills. Non-judgemental and positive attitude should be reinforced.

He should be encouraged to face the realities of his alcohol dependence life style. He should be encouraged and observed to take medication. It would be advised to follow up in out patient clinic. During his stay in hospital he can be involved in occupational therapies/recreational therapies. He can be further advised to attend Alcohol Anonymous group meetings. He can be referred to drug and alcohol de addiction centre and relapse prevention group for further advice and assistance. Social services may be involved to visit him in community to monitor progress and prevent relapse.

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