Transcript Drug Use Disorders PPT File

Field test version-1.00 May 2012
DO NOT UPLOAD ON THE INTERNET
Base Course
Drug Use and
Drug Use Disorders
Contents (Drug Use)
A. Introduction : 20 minutes
B. Learning objectives
C. Key actions
1. Establish communication and build trust 5 minutes
2. Conduct assessment 15 minutes
3. Plan and start management 40 minutes
4. Link with other services and supports 5 minutes
5. Follow up 5 minutes
Total Time: 1 hour 30 minutes
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Introduction (Pre session)
•
What legal and illegal drugs are commonly used in your
community?
•
Why do people use drugs?
•
Should people be forced to have treatment?
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Drug use management is important
• Drug use happens in almost all communities
•
Drug use is associated with substantial health and social
problems
– Drug use can lead to harm and dependence
– Injecting drug users have high rates of HIV and Hepatitis C
– Intensive cannabis use may result in psychotic disorders
•
Non-specialist clinicians can assess, manage or refer people
with drug use problems
•
You can make a difference
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Drugs we will cover
• Opioids
• Benzodiazepines
• Cannabis
• Stimulants
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Opioids
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Signs of opioid use and withdrawal
• Local names: [insert local names here]
• Opioid intoxication: drowsiness, being “on the nod”, slow
speech, small pupils, slow pulse, and depressed respiration
• Chronic use: self-neglect, constipation, lack of sex drive, signs
of injection, and complication of unsafe injection (hepatitis,
HIV/AIDS).
• Opioid withdrawal: anxiety, restlessness, dilated pupils,
muscle aches, nausea and vomiting, diarrhea, abdominal
cramps, headaches, raised pulse and blood pressure, yawning,
runny nose and piloerection (“goosebumps”)
– usually lasts 3-6 days
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Benzodiazepines
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Benzodiazepines
• Local names: [insert local names here]
• Benzodiazepine intoxication: sedation, slowed and slurred
speech, depressed respiration
• Chronic use is linked to impaired cognition and memory
• Benzodiazepine withdrawal: anxiety and agitation, muscle
cramps, abdominal cramps, raised pulse and blood pressure,
insomnia, and (when severe) seizures and delirium
– usually lasts one- two weeks
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Cannabis
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Cannabis
• Local names: [insert local names here]
• Cannabis intoxication: red conjunctivae, delayed
responsiveness, and normal pupil size
• Chronic use: self-neglect, poor hygiene, anxiety, and psychosis
• Cannabis withdrawal: mood swings, anxiety and muscle
cramps
– usually lasts about one - two weeks
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Stimulants
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Stimulants
• Local names: [insert local names here]
• Includes amphetamines (speed, base, ice) and cocaine
• Stimulant intoxication: hyperactivity, rapid speech and dilated
pupils, raised pulse and blood pressure, arrhythmias,
aggressive, erratic or violent behaviour
• Chronic use: self-neglect, cachexia , impaired cognition,
psychosis
• Stimulant withdrawal: initially fatigue, increased appetite,
irritability, depression and anxiety
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What causes drug withdrawal symptoms?
•
Our bodies and brains have mechanisms to minimize the impact of
drug use on our ability to function
•
When we use sedating substances like opioids and benzodiazepines
over a prolonged period of time, one of the ways our body adapts is
to release endogenous stimulants like adrenaline to keep us alert
A common effect is increased tolerance to a substance which means
that increased doses of the substance are needed to get the same
sedative effect
•
•
When we stop taking the sedating substance, it takes about a week
for our bodies to stop releasing the endogenous stimulants. In the
meanwhile we experience the unbalanced effects of the
endogenous stimulant. This is why the symptoms of sedative
withdrawal are similar to stimulant intoxication.
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Contents (Drug Use)
A. Introduction
B. Learning objectives
C. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Learning objectives
• To be able to identify drug use problems in three categories
– Hazardous use
– Harmful use
– Dependence
• To be able to provide brief (motivational) interventions to
reduce harmful/hazardous use
• To be able to offer harm reduction strategies for people
who inject drugs
• To be able to provide regular follow up
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Contents (Drug Use)
A. Introduction
B. Learning objectives
C. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Establish communication and build trust
• What is different about communication and trust with a
person with possible drug use compared to alcohol use
• The issues are mostly the same
• However, the added stigma and serious legal issues can make
communication more challenging
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Establish communication and build trust
• Identify the person's immediate expectations
– For what reason has the person come to see you?
– Consider that the person may be trying to manipulate you
• Manage the person's expectations
– Be honest about what you can and cannot do
• Assess the impact of drug use on the person's life
– How have their home and work life been affected
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Establish communication and build trust
•
Look for common ground
– Explain that you both want to improve the person's health
– Do not judge
– Challenge misconceptions but avoid confrontation
• Use good communication skills
– Ask open questions
– Remain neutral
– Explain your understanding of the situation to the person
– Always be honest
– Expect that it will take multiple meetings to build trust
– Honesty builds trust both ways. It can be useful to confirm
aspects of the persons history with family members.
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Contents (Drug Use)
A.
B.
C.
Introduction
Leaning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Assessment of hazardous/harmful drug use
Open mhGAP-IG p 69 and read the first column on the left:
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Assessment of hazardous/harmful drug use
What are examples of risks and harms from drug use that you
should ask about?
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Assessment of drug dependence
Read the assessment column of mhGAP-IG page 68
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Assessment of drug dependence
Drug dependence is pattern of symptoms that be clustered into
different categories.
1.Use
• Evidence of tolerance
• A physiological withdrawal state
2.Loss of control
• Strong desire or sense of compulsion to take drugs
• Difficulties in controlling drug use
3.Importance
• Progressive neglect of alternative pleasures or interests
• Drug use persisting despite harmful consequences
• Generally all three are present in dependence
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Examination and further investigation
•
You should always do a general physical examination
•
A physical exam should also assess for signs of drug use
• Signs of injection
• Pupils (relevant to most drugs)
• Stigmata of liver disease (relevant to injecting drug use)
• Cachexia (relevant to self-neglect)
• Weight loss
•
Look for common health complications of injecting drug use
• Evidence of HIV, Hepatitis B or C and TB infection
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Remember
• Always try to get a sense whether the person with drug use
problems is sober, intoxicated or in a state of withdrawal at
time of the interview
• If the person is intoxicated to the point that their behaviour is
inappropriate, you may want to ask them to come back later.
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Contents (Drug Use)
A.
B.
C.
Introduction
Leaning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Management overview
A. Managing associated health problems
B. Brief (motivational) interventions
• To facilitate cessation or reduction of drug use in
people with harmful/hazardous use
• To facilitate cessation or referral to treatment in people
with drug dependence
C. Harm reduction strategies for any injecting drug users
D. Advice for breastfeeding mothers
E.
In people who are dependent, referral for withdrawal
management and dependence treatment
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A: Treatment of associated health problems
• Common health problems
– due to drug injection
• HIV, hepatitis, skin infections, other infections
– due to effects of the drugs
• cannabis – anxiety, psychosis
• stimulants – anxiety, psychosis
– due to drug withdrawal
• i.e. nausea, vomiting, muscle aches, pain, anxiety,
insomnia
– due to living conditions
• TB, dental caries, STDs
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A: Treatment of associated health problems
• Principles of management of health problems in drug users
– if possible provide the treatment yourself rather than
referring
– consider vaccination against hepatitis A/B - no time like the
present!
– consider single high dose antibiotics rather than extended
regimens
– treatment in one place is generally better accepted than
treatment in multiple places, i.e. for combined HIV, TB and
opioid dependence
– consider safety when prescribing psychoactive medication,
arrange for supervised dosing (pharmacy or carer) or
dispense frequent small amounts if necessary
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B: Brief Interventions for people with
harmful/hazardous drug use
• The brief intervention technique is the same as in the alcohol
use module.
• Do you remember the components of a brief intervention
–
–
–
–
–
Engage the person in a conversation about benefits/harms
Challenge misconceptions
Avoid arguing
Assess the impact of the drug use on the person's life
State clearly the recommendation to cut down or stop harmful use
and your willingness to help
– Encourage people to decide themselves if they need to change
– If people are not ready to stop or reduce use, encourage them to
come back to discuss further, perhaps with a family member or friend
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C. Harm-reduction strategies for injecting drug use
• Open mgGAP-IG to p 71,
read section 2.6 “Harmreduction strategies” for
3 minutes
• What are some bloodborne viral illnesses that
you should test for
– HIV
– Hepatitis B/C
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D. Advice for breastfeeding mothers
• Strongly encourage breastfeeding mothers to avoid
psychoactive drugs
– cannabis has very high concentrations in breast milk
– stimulants are neurotoxic
• Refer to specialist care
• In all cases, advise and support mothers with drug use
disorders to breastfeed exclusively for at least the first 6
months, unless there is specialist advice not to breastfeed.
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Video: Assessment and brief intervention
• Lama is a 40 year old woman who comes to your clinic for a
checkup.
• She thinks she might be pregnant
• She asks you if cannabis can affect an unborn baby
• Quickly assess her drug use and manage with a brief
intervention
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Contents (Drug Use)
A.
B.
C.
Introduction
Leaning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Link with other services and supports
• People with a drug use problem may benefit from
– Self-help groups
– Support from family, friends and community members
– Other available community supports
• Housing and employment services
• Religious leaders
• People with drug dependence may benefit from
– Planned withdrawal services and dependence treatment
– Rehabilitation services (i.e. drug free environments)
• What is available in or near your community?
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Contents (Drug Use)
A.
B.
C.
Introduction
Leaning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
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Schedule follow-up
• Treating a person with drug use can be a long process
• It may take time for people to see their drug use as a problem
• You must be patient
• It is important to schedule regular follow up
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What would you do at follow up?
•
Re-assess drug use and its impact on the person’s life
•
Explore the person’s motivation to change their pattern of
drug use
•
Continue to provide brief interventions
•
Provide or refer for dependence treatment if necessary
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Referring to a specialist
• If the person continues to use despite brief interventions or
shows signs of dependence, refer for further treatment
• Successful referral is more likely when the person is
motivated. Continue to discuss the perceived benefits and
harms of the drug use with the person
• If the person is not ready for further treatment, it may be
better to ask the person to come back to discuss further,
perhaps with a family member or friend
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Key messages
• Health care providers can make a difference
• Treat associated health conditions
• Provide brief interventions to reduce hazardous/harmful
substance use and to stop drug use in those with drug
dependence.
• Offer harm reduction strategies for people who inject drugs
• Refer for further treatment if there is no improvement
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