Alcohol and Other Drugs: a Handbook for Health Professionals Appendix a Department Ofhealthandageing

Home , Bromazepam, Cocaine intoxication

Alcohol and Other Drugs: A Handbook for Health Professionals Appendix A www.nceta.flinders.edu.au Department ofHealthandAgeing. Alcohol andOtherDrugs:AHandbookforHealthProfessionals.AustralianGovernment National CentreforEducationand Training on Addiction (NCETA) Consortium.(2004), Suggested Citation: Publication approvalnumber:3315 Australian GovernmentDepartmentofHealthandAgeing GPO Box1920,CanberraACT2601. and rights shouldbeaddressedtotheManager, CopyrightServices,Info Access, Information Technology andthe Arts. Requests andenquiriesconcerningreproduction Commonwealth availablefromtheAustralianGovernmentDepartmentofCommunications, no partmaybereproducedbyanyprocesswithoutpriorwrittenpermissionfromthe This workiscopyright.ApartfromanyuseaspermittedundertheCopyrightAct1968, ISBN 064282312X © CommonwealthofAustralia2004 Flinders University National CentreforEducationandTrainingonAddiction(NCETA) Director Handbook ProjectHead Professor AnnMRoche of problemresolution. as anentrypointtothecomplexphenomenon ofdrugusingbehaviourand the challengingworld evolving areaofalcoholandotherdrugs.Thereaderistherefore encouragedtousethisresource by necessity‘provisional’,thismaybeconsideredtoespeciallythecaseinchangingand note thatthealcoholandotherdrugsfieldisparticularlydynamic.Whileknowledgeinany various resources,linksandcontactscitedthroughouttheHandbook.Finally,itisimportantto to eachofthetopicscovered. As a‘Handbook’ thisresourceprovidesonlyageneralsummaryoverviewofkeyissuespertinent roles suchashealthpromotion. will beofvalueandinteresttogroupssuchasteachers,communityworkersthosewithwider services workersincludingpsychologists,socialandcounsellors.Wealsoenvisagethatit But itisalsodesignedtobeausefulpracticaltoolforwiderangeofotherhealthandhuman the professionalalcoholandotherdrugsneedsofnon-specialistmedicalpractitionersnurses. This Handbookhasbeenproducedwithaverybroadtargetaudienceinmind.Largelyitwillcaterfor to theclinicianintheirday-to-daypractice. tained intheHandbookreflectsevidence-basedperspectivesthatareseentobeofpracticalvalue also capturedup-to-date,empiricallysoundhealthandmedicaladvice.Theinformationcon- gambling). Effortwasdirectedatproducingaresourcedocumentthatbothuser-friendlyand (such aspolydruguseandcoexistingmentalhealthproblems)newertopicareas expanded andprogressedinmanyways.Hence,thisnewversioncoversterritory since thelasteditionofHandbookwasproducedalcoholandotherdrugsfieldhaschanged, last editionprovedtobeavaluableandmuchsoughtafterdocument.Intheinterveningyears This Handbookisthethirdeditionofaresourceoriginallyproducedwelloverdecadeago.The About ThisHandbook Readers are encouraged toseekmorein-depthinformationfromthe i

Appendix A ii tium’s EditorialGroupincluded: advice andsupportthroughoutthedurationofproductionHandbook.Theconsor- getting thisprojectofftheground.Theotherconsortiummembersarethankedfortheirsound of ProfessorJamesRankin.Rankinisthankedforhisenthusiasmanddrivein the consortiumthatformedEditorialGroup,andthiswaslargelyatinstigation and collaborationofmanyplayerspartners.TheproposalfortheHandbookcamefrom The productionofthisHandbookonalcoholandotherdrugshasinvolvedtheinput,support Acknowledgments Illustrations bySimonKneebone. (CAMH) inCanadaforallowingusaccesstotheirpublication: We gratefullyacknowledgethegenerosityofCentre forAddictionandMentalHealth the aboveproductionofthisthirdeditionHandbook wouldnothavebeenpossible. leagues whocontributedtovariouspartsandstagesoftheprocess.Withoutinputall In addition,wewouldliketogratefullyacknowledgethefeedbackreceivedfrommanycol- of thedocument. College ofGeneralPractitioners(RACGP)whoassistedinthepilotingdraftversion immediately apparentandthisincludedourReferenceGrouptheRoyalAustralian The Handbookalsoinvolvedtheinputofarangeindividualsandgroupsthatarenot

Managing Alcohol, Tobacco and Other Drug Problems: Drug Other and Tobacco Alcohol, Managing A Pocket Guide for Physicians and Nurses and Physicians for Guide Pocket A Professor JamesRankin Professor BrianMcAvoy Professor RichardMattick Associate ProfessorRobertAli Professor AnnRoche(ProjectHead) iii

Appendix A List of Contributors

A wide range of contributors, each experts in specific areas, were involved in the writing of this Handbook. Some authors contributed whole chapters, others wrote smaller parts that were subsequently worked into larger sections or chapters. The authors who contributed to the Handbook in various ways are listed below.

Assoc. Professor Steve Allsop Dr John Litt Dr Michael Baigent Professor Brian McAvoy Dr Amanda Baker Ms Annie Madden Professor Bob Batey Professor Andrea Mant Dr Maggie Brady Ms Heather Proudfoot Dr Jan Copeland Dr Alison Reid Dr Kate Dolan Professor Ann Roche Professor Andrew Gilbert Ms Jodie Shoobridge Dr Tony Gill Professor Tim Stockwell Dr Linda Gowing Dr Maree Teesson Dr Paul Haber Dr Libby Topp Ms Jennifer Holmes Professor Greg Whelan Assoc. Professor Gary Hulse Professor Jason White Dr Nicole Lee Dr Adam Winstock Dr Patrick Lenehan Dr Alex Wodak Dr Nick Lintzeris Dr Chris Wurm

In addition to the authors and the oversighting Consortium, an important role was played by a team of NCETA staff who worked extensively on the editing of the Handbook to ensure its accuracy and consistency in terms of style and presentation. The final editorial team mainly comprised Dr Carolyn Edmonds, Jodie Shoobridge and Professor Ann Roche.

In addition, a broader technical team also worked in the production of the Handbook and this group included Laura Jackson, Niola Curtis, Veronica Fruend, Jane Malyschko, Joanne McDonald, Jodie Pearce, Sue Rayner, Chelsea Todd and Pamela Wright.

iv Overview Contents AT3 O-EIA NEVNIN 165 29 INTERVENTIONS PART 3:NON-MEDICAL 1 THE DRUGS PART 2: OVERVIEWANDINTRODUCTION PART 1: 4 lentv Teais177 157 167 105 147 95 137 73 59 79 31 119 AlternativeTherapies 14. PsychosocialInterventions 13. 3 OtherDrugs 12. Benzodiazepines 11. VolatileSubstances . HeroinandOtherOpioids 0 1 Cocaine 9. Ecstasy 8. Amphetamines 7. Cannabis . 6 Tobacco 175. Alcohol . 4 3. GeneralPrinciplesofManagementandIntervention OverviewandIntroduction 2. 1. rfc xxi vii v iv iii i Preface Contents –Detailed Contents –Overview List ofContributors Acknowledgments About ThisHandbook v

Appendix A PART 4: ISSUES FOR SPECIAL CONSIDERATION 183 15. Pregnancy and Drug Use 185 16. Surgery and Substance Use 193 17. Managing Chronic Pain 199 18. Coexisting Mental Illness 207 19. Injecting and Communicable Diseases 215 20. Drug Issues in Correctional Services 223 21. Health Professionals As Patients 229 2 2 . Gambling 233

PART 5: APPENDICES AND GLOSSARY 239 A. NHMRC Alcohol Guidelines – Short- and Long-term Risk 241 B. Laboratory Markers for Alcohol-related Damage 243 C. AUDIT – Interview Version 245 D. AUDIT – Self-report Version 247 E. Tip Sheet for Reducing Alcohol Consumption 249 F. Alcohol Withdrawal Assessment Scale (CIWA–AR) 251 G. Alcohol Withdrawal Observation Chart 253 H. The Five ‘A’s 255 I. CREATE 259 J. Proforma for Decision Balance Worksheet 261 K. Hepatitis C Referral Checklist 263 Glossary 265

vi .OEVE N NRDCIN3 OVERVIEWANDINTRODUCTION 1. Detailed Contents AT1 VRIWADITOUTO 1 PART 1:OVERVIEWANDINTRODUCTION eeecs15 14 10 10 References 4 Other SpecialNeedsGroups 7 Role ofHealthandHumanServicesProviders Standards ofCare Definitions ofDrugandAlcoholProblems Drug Usage ye fDusadterEfcs4 Types ofDrugsandtheirEffects eore 14 14 14 11 10 14 7 10 9 7 9 10 7 5 5 6 Resources Interpreting andTranslation 12 Secondary Prevention Prevention andTreatmentStrategies 12 Health Professionals’RolewithCulturallyandLinguistically DiverseGroups Health Professionals’RolewithAboriginalandTorresStrait Islanders Other FrontlineWorkers Medical PractitionersandNurses Drug Users’Rights Attitudes TowardsDrugUsers Substance Dependence Substance ‘Abuse’ Harmful Use Hazardous Use Terminology Routes ofAdministration Polydrug Use Other Drugs Tobacco Alcohol dniyn am 4 Identifying Harms The environment The individual The drug The 5 5 4 4 4 vii

Appendix A 2. GENERAL PRINCIPLES OF MANAGEMENT AND INTERVENTION 17 Harm Minimisation 17 Efficacy of Treatment 18 Early Recognition and Screening 18 Routine Enquiry About Alcohol and Drug Use 18 Screening Questionnaires 18 Biological Screening 19 Common Clinical Presentations 19 Assessment 19 Management of Low Level Problems 20 Psychosocial Interventions 21 Maintenance Pharmacotherapies 21 Pharmacotherapies for Alcohol Dependence 22 Acamprosate (Campral®) 22 Naltrexone (Revia®) 22 Disulfiram (Antabuse®) 22 Pharmacotherapies for Opioid Dependence 22 Buprenorphine 22 Methadone 22 Levoalphaacetylmethadol (LAAM) 22 Naltrexone (Revia®) 23 Withdrawal and Detoxification 23 Intoxication and Overdose 23 Coexisting Mental Health Problems 24 Drug Seeking 24 Clinical Features 24 Management 25 General Management Approaches 25 Readiness to Change 26 Resources 27 References 27

viii .ACHL31 ALCOHOL 3. AT2 H RG 29 PART 2:THEDRUGS eeisadHrs32 32 31 33 35 Measuring Consumption: The ‘Standard Drink’ Effects ofAlcoholConsumption Benefits andHarms Patterns ofDrinking Pharmacology fe-ae50 46 46 44 43 42 39 After-care 37 Alcohol Withdrawal Alcohol Dependence Alcohol Intoxication Brief Interventions Screening forAlcoholUse Alcohol Assessment Identifying Harms eaoim32 32 31 35 35 Groups atHighRiskforAlcohol-relatedHarm Identifying ‘At-risk’DrinkingLevels Metabolism Distribution Absorption efhl rus50 50 44 50 44 48 42 42 46 47 Pharmacotherapies toReduce Relapse/PromoteAbstinence Self-help Groups Self-help Resources 39 Pharmacological ManagementofAlcoholWithdrawal Psychosocial andPhysicalSupportDuringAlcoholWithdrawal General GuidelinesforAlcoholWithdrawalManagement 39 Assessment ofAlcoholIntoxication Acute AlcoholIntoxication Non-invasive Measures Invasive Measures Four KeyAssessmentSteps Early RecognitionofAlcohol-relatedProblems Home withdrawal management withdrawal Home AUDIT The Concentration) CAGE Alcohol (Blood BAC Estimating environment The individual The drug The groups years) Occupational (19–25 adults problems Women young children health and Unborn mental years) 18 with to (up People people Young 47 43 42 42 38 38 37 37 37 37 37 35 ix

Appendix A 3. ALCOHOL (continued) Alcohol-related Brain Injury (ARBI) 50 Wernicke–Korsakoff’s Syndrome 51 Resources 54 References 56

4. TOBACCO 59 Pharmacology 59 At-risk Groups 60 Detection and Assessment 60 Adverse Physical and Psychological Effects 60 Acute System Effects 60 Local Toxic Effects 60 Chronic System Toxicity 60 Cardiovascular disease 60 Respiratory 60 Cancer and malignancies 61 Gastrointestinal 61 Complications related to pregnancy and reproduction 61 Degenerative disease 61 Injuries and trauma 61 Environmental tobacco smoke (ETS) 61 Nicotine Dependence and Withdrawal 61 Nicotine dependence 61 Nicotine withdrawal effects 62 Psychological effects 62 Social Complications 62 Smoking Cessation Strategies 63 The Benefits of Quitting 63 Barriers to Assisting Smokers 63 Smoking Cessation Guidelines 63 The Five ‘A’s 65 CREATE 65 Decision Balance Worksheet 65 Pharmacotherapies 66 Nicotine replacement therapies (NRTs) 66 Bupropion (Zyban®) 66 Other Strategies 68 Resources 69 References 72

x .CNAI 73 CANNABIS 5. .APEAIE 79 AMPHETAMINES 6. ihrwl89 88 87 81 85 79 81 77 Withdrawal Assessment Using andStoppingAmphetamines Management andInterventionStrategies Physical andPsychologicalEffects Patterns ofUse 73 75 Pharmacology References 74 Management andInterventionStrategies Physical andPsychosocialComplications Pharmacology eeecs93 92 References Resources o-hraooia aaeeto ihrwl89 84 81 80 84 80 81 80 85 86 81 Non-pharmacological ManagementofWithdrawal 87 Identification andDetectionofAmphetamineUseRelated Problems 75 Acute AdverseEffects:IntoxicationwithComplications 75 76 Acute AdverseEffects:UncomplicatedIntoxication 75 75 75 Amphetamine-related Harms Long-term PsychologicalEffects 74 Long-term PhysicalEffects 74 76 Acute PhysicalandPsychologicalEffects 74 Routes ofAdministration 73 Availability andQuality Metabolism 74 74 Distribution Management andIntervention Tolerance, DependenceandWithdrawal Psychosocial Interventions Detection byUrineAnalysis Cardiovascular Respiratory Function Assessment High RiskGroups Harms AssociatedwithChronicUse Negative AcuteEffects Acute Effects Routes ofAdministration Common Names amRdcinMaue 91 90 90 Harm ReductionMeasures Intervention StrategiesPost-withdrawal Pharmacotherapies forManagingWithdrawalandRelapse Inpatient withdrawal management withdrawal Inpatient 89 xi

Appendix A 7. ECSTASY 95 Pharmacology 95 Patterns of Use 96 Physical and Psychosocial Complications 96 Physical Effects of Ecstasy 96 Hyperthermia 96 Hyponatraemia (‘water intoxication’) 97 Dose–response relationship 98 Liver damage 98 Neurotoxicity 98 Psychological Effects and Complications 99 Management and Intervention Strategies 99 Strategies for Different Levels of Use 99 Acute adverse effects 99 Treatment for Ecstasy Use 99 Pharmacological interventions 99 Non-pharmacological interventions 99 References 101

8. COCAINE 105 Pharmacology 105 Australian Street Names 106 Prevalence and Patterns of Use 106 Availability 106 Routes of Administration 106 Bingeing 107 Types of Users 107 Polydrug Use 107 Snorters 107 Injectors 107 Cocaine and Alcohol 107 Effects of Cocaine 108 Factors Influencing the Effects 108 Desired Effects 108 Other Acute Effects of Low Doses 108 Acute Effects of High Doses (‘Toxic Reactions’) 108 Effects of Chronic Use 109 Physical and Psychosocial Complications 109 Physical Problems Relating to Route of Administration 109 Intranasal users 109 Injecting users 109 Other Physical Problems 109 Cocaine-related Death 109 Psychological Problems 109 Social Problems 109 Cocaine Dependence 110

xii .COCAINE(continued) 8. .HRI N TE POD 119 HEROINANDOTHEROPIOIDS 9. eeecs115 References ihrwlSrie 125 123 123 125 123 124 119 119 Withdrawal Services Management andInterventionStrategies Harms AssociatedwithHeroinUse Dependent HeroinUse Withdrawal Tolerance Opioid Drugs Patterns ofHeroinUse 111 Management andInterventionStrategies hoi oan s 111 112 111 112 Treatment ofCocaineDependence Management ofWithdrawal Treatment ofToxicReactions Chronic CocaineUse betvs125 125 124 125 125 124 122 123 120 119 120 123 124 121 Key Components Objectives Social andCommunityHarms Psychological Harms Harms RelatedtoInjecting Overdose Features ofDependentHeroinUseinAustralia Natural HistoryofDependentHeroinUse The DependenceSyndrome Naltrexone Buprenorphine (Subutex®) Methadone 111 Morphine 110 Heroin 110 Clinical Screening Foetal Effects Cocaine WithdrawalSyndrome Assessment change to Readiness disorders Comorbid approaches skills General psychosocial of Acupuncture management Enhancement therapy Contingency Cognitive-behavioural Pharmacotherapy reactions toxic Acute Supportive care Supportive Setting 113 113 112 112 111 125 125 125 114 113 113 113 xiii

Appendix A 9. HEROIN AND OTHER OPIOIDS (continued) Frequent monitoring and review 126 Medication 126 Medication Regimes for Opioid Withdrawal 127 Post-withdrawal Interventions 130 Psychosocial interventions 130 Outpatient counselling 130 Therapeutic communities 130 Self-help groups 131 Naltrexone Treatment 131 Clinical aspects 131 Adverse events 131 Outcomes associated with naltrexone treatment 131 Substitution Maintenance Treatment with Methadone or Buprenorphine 131 Rationale, Objectives and Outcomes 131 Delivering Substitution Treatment in Australia 132 Problems with Maintenance Substitution Treatment 133 Principles of Safe and Effective Methadone/Buprenorphine Treatment 133 Resources 134 References 135

10. VOLATILE SUBSTANCES 137 Commonly Used Volatile Substances 137 Modes of Administration 138 Prevalence 138 Appeal 139 Physical Complications 139 Acute Effects 139 Negative Acute Effects 139 Effects at Higher Doses 139 Specific Physical Effects 139 Central nervous system 139 Maternal and neonatal 140 Heart 140 Lung 140 Kidneys, liver and bone marrow 140 Other Morbidity and Mortality 140 Psychosocial Complications 140 Management and Intervention Strategies 141 Detection and Assessment 141 Intoxication 141 Experimental, Recreational and Chronic Use 141 Primary Prevention Strategies 143 Resources 144 References 145

xiv 1 EZDAEIE 147 BENZODIAZEPINES 11. 2 TE RG 157 OTHERDRUGS 12. eeecs163 References nblcSeod 160 158 161 157 155 153 Over TheCounterDrugs Anabolic Steroids 149 Party Drugs 149 151 150 148 Hallucinogens 148 148 147 148 147 References Benzodiazepine Misuse Management andInterventionStrategies Prescribing Benzodiazepines High RiskGroups Uses andProblems Effects ofBenzodiazepines Patterns ofUse Metabolism Distribution Absorption Pharmacology netn rgUes162 Injecting DrugUsers eaie159 161 158 158 153 150 150 Non-prescription Medication 152 153 153 Ketamine GHB 149 Management andIntervention Physical andPsychologicalEffects 148 150 150 Drug DependentPatients Habitual DrugUsers(‘DoctorShoppers’) 151 Aged CareResidentialFacilities Dependence andWithdrawal Reviewing BenzodiazepinesinLong-termUsers:AStagedApproach Use inManagementofAnxietyandInsomnia Drug Interactions Precautions Rational UseofBenzodiazepines Long-term Effects Short-term Effects Other suppressants Cough Sympathomimetics Antihistamines Analgesics 162 162 161 161 161 159 xv

Appendix A PART 3: NON-MEDICAL INTERVENTIONS 165

13. PSYCHOSOCIAL INTERVENTIONS 167 Patient Readiness — A Model of the Process of Change 168 Pre-contemplation Stage 168 Contemplation Stage 169 Preparation Stage 169 Action Stage 169 Maintenance Stage 169 Clinical Strategies 169 Patient-centred Approach 169 Decision Balance 169 Building A Therapeutic Alliance 169 Empathy and reflective listening 170 Using open ended questions 171 Reflective listening 171 Summarising 171 Roadblocks to empathy 171 Motivational Interviewing 172 Brief Motivational Interviewing 173 Problem Solving 174 Goal Setting 174 Relapse Prevention 175 Quality of Life 175 References 176

14. ALTERNATIVE THERAPIES 177 Evidence of Effectiveness 177 Acupuncture 178 Hypnosis 179 Conclusions 179 References 180

xvi AT4 SUSFRSEILCNIEAIN183 PART 4:ISSUESFORSPECIALCONSIDERATION 6 UGR N USAC S 193 SURGERYANDSUBSTANCEUSE 16. 185 PREGNANCYANDDRUGUSE 15. 7 AAIGCRNCPI 199 MANAGINGCHRONICPAIN 17. eore 206 205 204 Resources The Patient–ClinicianRelationship The PotentialforAdverseInteractions ct n hoi an199 194 200 192 191 Assessment andPainManagementinDrugUsers Acute andChronicPain 185 191 Alcohol Tobacco 187 References Child Protection Neonatal AbstinenceSyndrome(NAS) Information onAlcoholandDrugEffects Assessment Opioids eeecs198 197 197 References Stimulant Use Benzodiazepines eedneadTlrne202 201 201 203 Principles ofPainManagementinOpioidDependentPatients 202 190 Preventing DrugDependenceinPatientswithChronicNon-malignant Pain Dependence andTolerance 189 Alternative OptionsinManagement Screening forSubstanceDependence 189 188 187 190 Ecstasy Psychostimulants —AmphetaminesandCocaine Heroin Cannabis Tobacco Alcohol loo n otoeaieMriiy194 195 Peri-operative ManagementofAlcohol-relatedComplications Alcohol andPost-operativeMorbidity aaeetSrtge 197 Management Strategies Terminal illness Terminal Buprenorphine maintenance Methadone 194 196 204 204 203 xvii

Appendix A 18. COEXISTING MENTAL ILLNESS 207 Epidemiology 207 Terminology 208 Some Specific Associations 208 From a Drugs Perspective 209 From a Mental Health Perspective 209 Management 210 What Works? 210 Principles of Care 210 Assessment and Management 210 Harm Minimisation 211 Resources 212 References 213

19. INJECTING AND COMMUNICABLE DISEASES 215 Infective Problems Associated with Injecting Drug Use 216 Blood Borne Communicable Diseases 216 Hepatitis C 216 Testing for HCV 216 Natural History 217 Assessing Patients for Treatment 217 Antiviral Therapy 217 Managing Patients who have Failed Therapy or are Ineligible for Treatment 217 Liver Transplantation in HCV 217 Prevention of HCV 217 Alcohol and HCV 218 Hepatitis B 218 Testing for HBV 218 Natural History 218 Treatment of HBV 218 Hepatitis D 219 Human Immunodeficiency Virus 219 Testing for HIV 219 Treatment of HIV 219 Prevention 219 Effect of HIV on IDU Problems 219 HTLV/I/II 220 Resources 221

xviii 1 ELHPOESOASA AINS229 HEALTHPROFESSIONALSASPATIENTS 21. 223 DRUGISSUESINCORRECTIONALSERVICES 20. 2 ABIG233 GAMBLING 22. eeecs237 233 236 234 227 References Treatment/Referral Options Presentation ofProblemGamblers 231 Problem Gambling 230 Being aHealthProfessionalwithDrugorAlcoholProblem 230 Dealing withaColleagueDrugorAlcoholProblem 223 Treating aHealthProfessionalwithDrugorAlcoholProblem References 224 224 224 Interventions toReduceRiskBehaviourandTransmission Prevalence andTransmissionofBloodBorneViralInfections History ofImprisonmentandPrevalenceInjecting Patterns ofDrugUseAmongPrisoners dniyn rbe abes234 231 230 225 225 Identifying ProblemGamblers 225 225 The StepstoTake Registering Authorities Syringe ExchangeSchemesinPrison Methadone MaintenanceTreatment Condoms Bleach Programs xix

Appendix A PART 5: APPENDICES AND GLOSSARY 239

A. NHMRC Alcohol Guidelines – Short- and Long-term Risk 241 B. Laboratory Markers for Alcohol-related Damage 243 C. AUDIT – Interview Version 245 D. AUDIT – Self-report Version 247 E. Tip Sheet for Reducing Alcohol Consumption 249 F. Alcohol Withdrawal Assessment Scale (CIWA–AR) 251 G. Alcohol Withdrawal Observation Chart 253 H. The Five ‘A’s 255 I. CREATE 259 J. Proforma for Decision Balance Worksheet 261 K. Hepatitis C Referral Checklist 263 Glossary 265

xx xxi

Appendix A xxii Part 1

Overview and Introduction

1 2 Chapter 1

Overview and Introduction Overview Introduction

ROBLEMS caused by the use of psychoactive drugs touch all areas of medicine and health care. Some problems are well known and highly visible such as the respiratory ill- Pnesses caused by smoking, liver disease from harmful alcohol consumption and overdose from heroin injection. Others are more subtle and often missed by health professionals as an underlying cause of a wide range of health and social harms.

Personal and social problems from drug use are substantial and cut across all domains of functioning including personal relationships, family life, employment and psychological health.

The health and economic costs associated with the use of drugs are high, with costs of legal drugs estimated to be substantially higher than those from illegal drugs. The annual cost of drug use in Australia is estimated to be $34.4 billion (Collins & Lapsley, 2002) of which: $21.1 billion was from tobacco $7.6 billion from alcohol $6.1 billion from illicit drugs

The Australian Institute of Health and Welfare estimated that in 1998 there were 23,313 drug-related deaths in Australia of which 19,019 were due to smoking tobacco, 3,271 to risky alcohol use and 1,023 to illicit drug use (Ridolfo & Stevenson, 2001). The bulk of the latter comprised deaths from heroin overdose.

3 In addition to drug-related deaths, in TYPES OF DRUGS AND 1997–1998 there were: THEIR EFFECTS 142,525 hospital separations attributable to tobacco smoking Identifying Harms 71,422 attributable to risky alcohol use Alcohol- and drug-related harms are not spe- 14,471 to illicit drugs cific to the effects of the drug. Harms result from the interaction between:

Overview There are three main patterns of risky drug The drug

Introduction use with corresponding patterns of problems. These are: patterns of use (how much, when used, how often) intoxication (e.g. violence, falls, road and other drugs used trauma, overdose) regular use (e.g. liver disease, cancer) The individual dependence (e.g. withdrawal symptoms, age, weight, gender and general health social problems) tolerance and previous experience of the substance including intoxication, after ef- These three distinct patterns of use can oc- fects and withdrawal cur within the one person, or in different individuals. expectations of use and effects current mood and psychological health

The environment Factors that influence the drug’s effects and Intoxication I patterns of use such as: social settings and company context of use patterns of drug use according to ritual or culture DependenceD RegularR Use

DRUG USAGE

Knowledge and understanding about patterns and correlates of drug use are derived There are also growing problems associated from various sources including surveys. Sur- with injecting drug use including the spread veys of drug use are usually (1) conservative of blood borne viruses. While the rate of HIV estimates of prevalence and (2) do not give infection amongst Australian injecting drug an indication of the number of people using users is still very low by world standards drugs in problematic ways. In the clinical set- (1–2%), hepatitis C is an emerging concern ting careful, individualised assessment is re- and is likely to generate some thousands of quired to determine patterns and levels of cases of liver disease in future years use. The following provides brief highlights (NCHECR, 1999). of key drug use patterns (see relevant chapters for more detail on specific drugs).

4 community. ians is2to3timeshigherthanthebroader Tobacco useamongstIndigenousAustral- females smokeddaily(AIHW,2002). Survey foundthat21%ofmalesand18% The 2001NationalDrugStrategyHousehold Tobacco a widerangeofacuteandchronicharms. sionals astheyarestronglyassociatedwith sumption areaconcernforallhealthprofes- (Heale etal.,2000).Heavierpatternsofcon- 32% offemalesdosoatleastonceamonth exceed theselimitsand46%ofmales ing). However, therearemany who drinkers all, whenpregnant,notdrinkingbeforedriv- strictions areobserved(e.g.drinkinglessifat precautionsandre- women, provided certain than 6standarddrinksformenand4 be lowriskonanoccasionalbasis,ienomore A higherlevelofintakeisnowconsideredto males andfemalesrespectivelyonoccasion. women, andnomorethan64drinksfor standard drinksperdayformenand2 fine lowriskregularuseasnomorethan4 new AlcoholGuidelines(NHMRC,2001)de- and MedicalResearchCouncil’s(NHMRC) cohol inthepastyear.TheNationalHealth tralians aged15andoverreportdrinkingal- Most Australiansdrinkalcohol–80%ofAus- Alcohol publications/pdf/ds9.pdf www.nhmrc.gov.au/ Tobacco See Chapter4 Alcohol See Chapter3 Chapter 1 sity inpatternsofuse. of drugsislikelytohavecontributed todiver- an alternative.Increasedeaseofavailability (e.g. amphetamines, alcohol)may beusedas age ofsomedrugs(e.g.heroin)other substitution alsooccurs.Whenthereisashort- likely touseavarietyofsubstances.Drug are nolongervalid. usersare Mostillicitdrug were stimulant users. These characterisations ofuser,identified asadistinctcategory as used.primarily For instance, heroinuserswere orclassofdrug, useby thedrug, illicit drug Until recentlyitwascommontocharacterise Polydrug Use of age(Halletal.,2000). ers or0.7%ofAustralians aged15to54years approximately 74,000dependentheroinus- estimated thatintheyear 2000therewere and ofcocaine3–4%thepopulation.Itis Lifetime useofheroinisestimatedtobe2% boys (AIHW, 2002). where usebygirlsismoreprevalentthan likely touse,withtheexceptionofteenagers the last12months. Malesaregenerallymore usingamphetaminesin 20–29 years reported increasingly prevalent: oneinninemalesaged Amphetamine andecstasyusehasbecome time intheirlives. 12 months(AIHW,2002)and33%atsome 14 orover theprevious having useditduring in Australiawith13%ofallindividualsaged Cannabis isthemostwidelyusedillicitdrug Other Drugs sons includingitshighlyaddictivenature. young peopleisofconcernforseveralrea- use. Earlyuptakeoftobaccosmokingby there isnoestablishedsafeleveloftobacco Very fewpeoplesmokeonlyoccasionallyand See Chapters5–12 5

Overview Introduction Certain associations are well recognised; problematic use) and for a single drug only, for example: or provide separate substance specific measures. Careful decisions regarding prioritisation

cigarettes and alcohol often go hand for treatment are needed. This should be done in hand, particularly where heavy use in consultation with the client/patient. of either substance is involved cannabis smokers are almost invariably Routes of Administration tobacco smokers (although obviously the reverse is not the case) Drugs can be taken in various ways. The Overview heroin users often also take drugs such as mode of administration is a significant medi- Introduction cocaine and benzodiazepines, and nearly ating factor on the effect of a drug. Various all heroin users are also cigarette smokers routes of administration are preferred because they can enhance or facilitate drug ef- heavy drinkers also often use illicit drugs fects. Different modes of administration have advantages and disadvantages. The most Many illicit drug users possess sophisticated common routes of administration are: pharmacological knowledge. Users often ex- hibit considerable skill in the titration of vari- oral ingestion: probably the oldest and the ous substances when used in concert with one most common form of taking drugs. Ad- another. For example, combinations of drugs vantages are convenience, no special such as heroin and cocaine (known as paraphernalia is required and degree of ‘speedballs’ *) allow the sedative action of one safety for some drugs. Disadvantages are drug (i.e. the heroin) to take the sharp edge the slow absorption of some substances off the stimulant (i.e. the cocaine). Similarly,

some substances are less commonly taken chewing: used for coca leaf, tobacco, when using another preferred drug e.g. some betel-nut and tea. Absorption occurs users avoid taking ecstasy and alcohol con- across the oral mucosa currently. nasal insufflation: includes snuffing, nasal inhalation or snorting. Absorption is Multiple substance use complicates the as- through the nasal mucosa. Snuffing can sessment process. Signs and symptoms of be used for cocaine, powdered opium, intoxication for various drugs can be similar. heroin and tobacco. Sniffing of amyl nitrite Also concurrent use can complicate with- occurs, as does sniffing of petrol and other drawal. Polydrug use also confounds our un- volatile substances derstanding of dependence problems smoking: is used for a wide variety of sub- (Gossop, 2001). A person who uses a range stances including tobacco, cannabis, of different psychoactive substances may not opium, heroin, cocaine, amphetamines be dependent on all drugs that he/she uses. and phencyclidine (PCP) Comprehensive drug use histories are re- rectal administration: commonly used in quired, and no assumptions should be made medical treatment, it is also a method about patterns of use or non-use. It is impor- sometimes used by drug users. Disadvan- tant to note that most available assessment tages are the potential for irregular, unpre- tools assess dependence (and not usually dictable and incomplete absorption parenterally (via injection): became possible in the late 19th century with the de- * Note that the term ‘speedball’ some- velopment of the hypodermic needle. Ar- times also refers to a combination of guably this has irrevocably transformed heroin and amphetamine. hedonistic drug use. Administration can be intravenous (via a vein), intramuscu-

6 of the international andofficialclassifications of theinternational pejorative thanotherterms. However, some nology is‘problematicuse’asthisless problems. InAustralia,thepreferredtermi- andalcoholuseassociated drug scribe inthelanguageusedtode- some variations Throughout thisHandbook,youwillnote Terminology ministration andreferences reading. for further routesof ad- about commonnamesofdrugs, containsadditionalusefulinformation America Abuse (NIDA)locatedintheUnitedStatesof The websiteoftheNationalInstituteDrug 2ofthisHandbook. Part chronic use, refer totheindividualchaptersin acute effects, highdoseeffects andeffects of includingadiscussionof drugs, of particular For regardingspecificeffects moreinformation tential adverse healtheffects. theirintoxication effectsand describes andpo- Table 1–1liststhemajorpsychoactive drugs and quitting. be ausefulsteppingstonetocuttingdown route ofadministrationtoanothermayalso are especiallyimportant. Changingfromone administer drugs. Safe injectingtechniques tunities toeducateusersaboutsaferways Harm minimisationstrategiesprovideoppor- eases andtissuedamage dis- transmission ofviralandbacterial including healthrisks range ofimportant disadvantages. withita Injectioncarries der theskin).Eachhasadvantagesand lar (viaamuscle),orsubcutaneous(un- See Chapters3–12 www.nida.nih.gov Chapter 1 Alcoholism (NIAAA) ontheirwebsite. Thesaurus Refer toNationalInstituteonAlcoholAbuse and disorder intheindividualuser. nificance despitetheabsenceofany current ofusethatarepublic healthsig- to patterns social consequences. Hazardoususerefers health problems; somewouldalsoinclude quences canincludephysical and/ormental consequences for theuser. These conse- ofharmful stance usethatincreasestherisk Hazardous usereferstoapatternofsub- Hazardous Use insomesystemsas: egorised usehasbeenformally cat- Problematic drug ALCOHOL PROBLEMS DEFINITIONS OFDRUGAND drugs) ormental(e.g.depressive episodes physical (e.g.hepatitisfollowing injectionof ing damagetohealth.Themaybe of psychoactive substanceusethatiscaus- Harmful use(ICD–10)isdefinedasapattern Harmful Use changeably. such as‘patient’and‘client’areusedinter- of healthandhumanservicesworkersterms As thisHandbookisintendedforawiderange tive orvalue-ladenterms,labelslanguage. The preferenceistoavoidtheuseofnega- include termssuchas‘abuse’or‘misuse’. substance dependence substance abuse harmful use hazardous use AODVol1/Aodthome.htm www.etoh.niaaa.nih.gov/ 7

Overview Introduction Table 1–1 Intoxication and potential adverse health effects

Intoxication effects Potential adverse health effects

Alcohol • reduced pain and anxiety • trauma and a range of effects on • feeling of wellbeing cardiovascular, respiratory, • lowered inhibitions gastrointestinal, haematological and neurological systems • dependence Overview Opioids • •

Introduction pain relief respiratory depression and arrest • heroin • euphoria • nausea • codeine • drowsiness • confusion • fentanyl • constipation • morphine • sedation • methadone • unconsciousness • buprenorphine • coma • pethidine • tolerance • dependence

Stimulants • increased heart rate, • rapid or irregular heartbeat • amphetamines blood pressure, • reduced appetite • cocaine metabolism • weight loss • • ecstasy/MDMA feelings of exhileration, • heart failure energy, increased mental • methyulphenidate • dependence alertness • nicotine • caffeine

Depressants • reduced pain and anxiety • confusion • barbiturates • feelings of wellbeing • fatigue • benzodiazepines • lowered inhibitions • impaired coordination, memory, • slowed pulse and judgement breathing • respiratory depression and arrest • lowered blood pressure • dependence • poor concentration

Cannabinoids • euphoria • cough • cannabis • slowed thinking and • frequent respiratory infections • hash reaction time • impaired memory and learning • confusion • increased heart rate • impaired balance and • anxiety coordination • panic attacks • tolerance • dependence

Other – includes: • various effects • various effects • hallucinogens such as LSD; dissociative anaesthetics (ketamine, PCP); inhalants (solvents, nitrites and other gases); steroids

Source: adapted from the US National Institute of Drug Abuse (NIDA) website. Information about alcohol has been added.

8 DSM–IV–TR (APA,2000)Criteriaforsubstancedependence Table 1–2 following, within a12monthperiod: occurring tress, asmanifested by oneormoreofthe ordis- ing toclinicallysignificantimpairment ofsubstanceuselead- maladaptive pattern IV–TR (APA, 2000,p. 199). Itisdefinedasa Substance ‘abuse’ usedby DSM– isaterm Substance ‘Abuse’ justify adiagnosisofharmfuluse. however, inthemselves, arenotsufficientto social consequences. Socialconsequences, use commonly,butnotinvariably,hasadverse secondary toheavyalcoholintake).Harmful recurrent substance-relatedlegal problems hazardous use insituationswhichitisphysically failure tofulfilmajorroleobligations 7. 6. 5. 4. 3. 2. 1. occurring at any time in the same 12 month period. impairment or distress, as manifested by three (ormore)following, ofthe The maladaptive pattern of substance use, leading to clinically significant

associated with use Substance use is continued despite awareness ofrecurrent problems Social, occupational or recreational activities are given up orreduced or torecover from its effects A great deal oftimeactivitiesspent is on necessary thetoobtain substance use substance There is a persistent desire or unsuccessful attempts to cut down or control was intended The substance is often taken in larger amountslongeror overa periodthan relieve or avoid withdrawal symptoms the substance or where the same (or a closely related) substance is taken to Withdrawal, asdefined eitherthecharacteristic by withdrawal syndromefor diminished effect with continued use of the same amount of the substance the substance to achieve intoxication or desired effect ora markedly Tolerance, as defined by either a need for markedly increased amounts of Chapter 1 quences ofrepeateduse. compulsive use, onlytheadverse conse- ised by withdrawal, of toleranceorapattern Unlike dependence, ‘abuse’ isnotcharacter- drug. for dependenceare The actualcriteria symptoms arepresentuponcessation ofthe lems. Tolerance hasdeveloped andwithdrawal substance despiteconsiderable relatedprob- in whichtheindividualwillcontinuetouse cognitive, behavioural andphysiological signs defined (APA, setof 2000)asacharacteristic Substance dependenceontheotherhand,is Substance Dependence of thesubstance lems causedorexacerbated by theeffects prob- or recurrentsocialinterpersonal continued usedespitehavingpersistent 9

Overview Introduction summarised in Table 1–2 DSM–IV–TR (2000) who uses drugs or the health professional. Criteria for Substance Dependence. Participation in an illegal behaviour does not mean that individuals surrender their basic In addition to these criteria, the World Health health and human rights. Illicit drug users Organization (WHO) International Classifica- should be treated in the same way as other tion of Diseases, 10th Edition (ICD–10) sug- people, that is, as individuals with specific gests that another essential characteristic of needs requiring information and communi- dependence is that the individual must pos- cation on all options, professional diagnosis and where appropriate, treatment.

Overview sess a strong desire to take the substance and is indeed consuming it (Proudfoot & Introduction Teesson, 2000). ROLE OF HEALTH AND HUMAN It is important to note that many problems as- SERVICES PROVIDERS sociated with the use of alcohol or other psychoactive drugs do not involve dependence. That is, you do not need to be dependent on a Medical Practitioners drug to experience harms from its use. and Nurses Medical practitioners and nurses who are not specialists in drug and alcohol have a criti- STANDARDS OF CARE cally important role to play in the provision of drug and alcohol treatments. Attitudes Towards Drug Users General practitioners and other primary care health professionals are particularly well Psychoactive drug users often experience dis- suited for this role because: crimination and stigma when accessing health services. While not all health professionals 85% of the population visit a general prac- discriminate against drug users, poor treat- titioner at least once per year ment and discriminatory practices have been general practitioners and primary health identified as primary barriers to accessing professionals are usually the first point of health care. contact with the health care system patients are often at a learning moment Negative attitudes are often based on stere- and expect to receive lifestyle advice from otypes and fears. Such stereotypes can result general practitioners in discrimination, stigma and marginalisation. general practitioners are in an ideal posi- Like other groups in the community, drug us- tion to link prevention with comprehensive, ers are a diverse group with differing needs continuing and holistic care and backgrounds. In the health care context, general practitioners provide a range of recognising the diverse needs of every indi- services that span the health care con- vidual is critical to professional and effective tinuum from prevention of illness to treat- treatment and ensures appropriate standards ment and rehabilitation of care are met. (RACGP National Preventive & Community Drug Users’ Rights Medicine Committee, 1998) Treating all illicit drug users as ‘drug seeking’, unreliable and disruptive will not result in a positive outcome for either the person

10 including: care ofpatientscanbeundertaken petencies, amorecomprehensive role inthe For andalcoholcom- clinicianswithspecificdrug fective inspecialistandnon-specialistsettings. haveThese interventions beenshown tobeef- nurses canprovide. These include: of treatmentthatmedicalpractitionersand the effectiveness andbenefits ofinterventions There isagrowing bodyofevidence about placed to: Medical practitionersandnursesareideally treatment ofmedicalcomorbidities counselling treatments pharmacotherapy management ofdetoxification motivational interviewing management ofintoxication andwithdrawal follow-up andcarecoordination monitoring andalcohol in drug referral toclinicianswithspecialistskills viewing, andrelapseprevention counselling, includingmotivational inter- opioid dependence forpharmacotherapy tobacco, alcoholand detoxification, includinghomedetoxification to alesserextent cannabis for interventions tobacco,brief alcoholand andadvice information assessment screening time coordinate careandfollow uppatientsover ment whenrequired;and refer for specialistassessmentandtreat- provide interventions andalcohol-relatedproblems identify drug- and alcoholtoallpatients provide relevant aboutdrugs information Chapter 1

perspective. harm minimisationandearly intervention frontline workersespeciallyfromaprevention, there isalsoanexpandedroleforgeneralist in relationtopharmacologicalinterventions) and technicalinrecentyears(mostnotably and treatmentshavebecomemorespecific specialist professionals.Whileinterventions problems istheexclusiveprovinceof tervention foralcoholandotherdrug(AOD) andin- It isnolongerassumedthatsupport frontline workers include: Key professional groupsidentifiedaspivotal for problems. alcoholanddrug any professional inapositiontointervene rolefor tablished andidentifiesanimportant hasbeenwelles- intervention cacy ofearly increased accordingly. Evidencefor theeffi- workers has for healthandhumanservices roles andintervention The potentialsupport creased substantiallyover thepastdecade. usehasin- sociated withalcoholanddrug The complexity anddiversity ofproblems as- Other Frontline Workers follow-up andreview monitoring neonates; and alcohol-related problems andtheir care ofpregnantwomenwithdrug-and management ofpsychiatriccomorbidities teachers andeducationpersonnel nity-based workers workers, youth andothercommu- workers welfare professionals, includingsocial police andlaw enforcement personnel groups and counsellingsupport groups, self-helpgroups, churchgroups nity groups includingparentandfamily volunteer workers inavarietyofcommu- workers andpsychologists practitioners, nurses, Indigenoushealth general healthworkers suchasmedical specialistworkers alcohol andotherdrug 11

Overview Introduction Health Professionals’ Role with Aboriginal and implication of criticism. Research into self- quitting amongst Indigenous people Torres Strait Islanders suggests that health care workers can be There is a range of special considerations in more influential than they think (see Table relation to the AOD use of Indigenous Aus- 1–3). tralians. Patterns and correlates of use are often quite different and health care needs The Australian Drug Information Network more complex than for the wider community. (ADIN) contains useful links: Overview

Introduction Proportionately fewer Indigenous people drink than in the Australian community at large. How- www.adin.com.au/ ever, amongst those who consume alcohol the indigenous.html majority do so at hazardous and harmful levels, often drinking heavily on a single occasion. There is often intense social pressure for Indig- Health Professionals’ Role with enous drinkers to continue to drink. Relatedness Culturally and Linguistically to others is deeply embedded within Aboriginal Diverse (CALD) Groups social life and sharing alcohol (and increasingly other drugs) naturally plays an important part in Cultural background and drug use this. Public pressure to share and socialise Australia is ethnically a highly diverse country. around alcohol is very strong, and those who A person’s cultural background i.e. country of try to moderate or give up may be criticised. birth, language spoken at home, religion and Health care workers can be valuable aids in sup- ethnic background may have an impact on drug porting moderate use or cessation. use and/or associated problems and their reso- lution. Different cultures vary in their attitudes Prevalence of tobacco smoking is 2 to 3 times to and use of alcohol and other drugs. Alcohol higher than the national average, and there consumption, for example, varies greatly within are very high rates of cannabis (yarndi, ganya) and between countries. In Italy, for instance use. It has also been recognised recently that wine is commonly consumed with meals but rates of injecting drug use amongst young In- intoxication is not accepted. Some cultures fa- digenous people have grown exponentially vour the use of drugs little known in Australia and are associated with very high levels of (e.g. khat, betel nut), while alcohol is much less diseases such as hepatitis C. There are also widely used in many countries, including some increasing levels of use of other drugs such which are significant sources of refugees and as heroin with high levels of needle sharing. migrants to Australia. In many Asian countries, the traditional use of opioids once tended to be by smoking. However, this is rapidly chang- General practitioners and other health care ing with injecting becoming increasingly com- workers have considerable potential to help mon among Asian populations. motivate Indigenous patients to reconsider their drinking and/or drug use. Health professionals should not feel constrained Religious affiliation may also be relevant. Re- (e.g. by fears of being culturally inappropri- ligious observance is often an important as- ate), to provide a range of brief interventions pect of culture, and may play a part in the to patients just because they are Indigenous. manner and extent of drug use. A person of As is the case with any patient or client, such Islamic background for instance may develop advice should be offered sensitively and in a problem with alcohol, but be less willing to a non-judgmental manner, and avoid any discuss it and may fear community criticism.

12 Why healthcareworkersareinfluentialamongstIndigenouspeople Table 1–3 evidence of evidence harm and providing advice Personalised knowledge specialised Respect for doctor’s role of Expectations the identified an of attending stigma Avoidsthepotential Privacy of consultation an informed outsider an informed from Neutral advice esnExplanation Reason Chapter 1 about alcohol awareness. Indi about alcoholawareness. talk general a than influential ismore problem presenting individual’s the to consumption alcohol on Linking advice behaviour. use drug other and drinking in for change motivate to potential significant with doctors and provides people, Indigenous amongst authority with considerable investsthem This specialised of body. knowledge the in Medical practitioners family responsibilities. their use on drug and/or drinking effect of thepatient’s the stress to important Itis minimal. may be these links about patient’s knowledge as possible, where problems drug-related or alcohol- with problem thepresenting link to important particularly It is advice. give diagnose and to problems, health their about talk honestly workers to care health and doctors expect patients Indigenous confidentiality. necessary the provides and service, drug other and alcohol offence. causing with without friends andfamilymembers, sessions drinking in toparticipate refusal an individual’s an ext Having particular value. be of can anoutsider advice from to authoritative drink, pressures social intense face of the In people. indigenous other with matters drug-related or alcohol- discuss to intrusive findit sometimes known can to patient the workers health Community patient’s or community. family ofthe not an ‘outsider’, usually is a doctor because partly change, consider to individual the motivate can behaviour drinking changing advice on Professional patient. to theindigenous useful particularly canbe evidence Such misuse. alcohol of effects harmful the of proof objective provide which of results the tests, of biological well offers respond to particular are known to have to known are particular ernal reason can legitimise can reason ernal g enous patients seem to seem patients enous 13

Overview Introduction The circumstances under which a person Resources came to Australia may also be important. Those migrating under family reunion quo- NSW Drug and Alcohol Multicultural Educa- tas may have more support than refugees who tion Centre, DAMEC. may have previously faced poverty, illness and war. Some individuals may have depression www.damec.org.au or post-traumatic stress disorder following trauma or torture in their country of origin. Overview Prevention and Introduction Treatment Strategies OTHER SPECIAL NEEDS GROUPS Prevention and treatment programs need to take into account the characteristics of individuals with Indigenous and non-English speaking There are several other groups who have backgrounds. Different cultural values as well special needs in relation to AOD use. These as language issues need to be considered in groups may not engage well in treatment un- any prevention strategy. There is untapped less their special needs are met. These potential for ethnic newspapers and broadcast- groups include: ing services to be used in primary prevention strategies. those located in rural and remote areas women Secondary Prevention those of different sexual orientations Many screening tools have not been validated youth with different ethnic or cultural groups and should be used and interpreted with care. The The last group, youth, are particularly impor- AUDIT alcohol screening tool has been vali- tant to highlight. More young people are en- dated with different cultural groups. gaging in problematic AOD use at younger ages. They are especially vulnerable to AOD- See Chapter 3 related problems due to age and inexperience. Alcohol Health and human services workers are in- ‘The AUDIT’, p. 45 creasingly called upon to provide youth- friendly and youth-appropriate services. Interpreting and Translation The use of skilled interpreters with the appropriate dialect and of the patient/client’s preferred gender is crucial. It is inappropriate to use family members as interpreters. Even if the patient does not see the need, an interpreter may still be required to ensure an accurate assessment and appropriate management strategy.

14 RACGP NationalPreventive&CommunityMedicineCommittee1998, NHMRC (NationalHealthandMedicalResearchCouncil)2001, Heale, P., Stockwell, T., Dietze, P., Chikritzhs, T. &Catalano, P. 2000, Gossop, M. 2001, ‘A webofdependence’, AIHW (AustralianInstituteofHealth&Welfare)2002, REFERENCES Ridolfo, B.&Stevenson,C.2001, Proudfoot &Teesson2000, Collins, D.J.&Lapsley,H.M.2002, Hall, W., Ross, J., Lynskey, M.,Law, M. &Degenhardt,L. 2000, APA (AmericanPsychiatricAssociation)2000, Stockwell, T., Heale, P., Dietze, P., Chikritzhs, T. &Catalano, P. (inpress), ‘How muchalcohol NCHECR (NationalCentreinHIVEpidemiologyandClinicalResearch)1999, Alcohol ResearchCentre, no. 44.,University ofNSW, Sydney. Medical Journal of Australia of Journal Medical Canberra. is consumedinAustraliaexcessofthenewNHMRCnational drinkingguidelines?’, Australia. University of ResearchInstitute,Curtin Technology,National Drug Perth, Western in Australia, 1998 Australia, in 1998–9 Australia in Abuse into Practice: Guidelines for the Implementation of Prevention in the General Practice General the in Prevention of Implementation the for Guidelines Practice: into Users Are There in Australia? in There Are Users Disorders Consumption in Australia, 1998. Australia, in Consumption Survey: First Results First Survey: Hepatitis C and Sexually Transmissible Infections in Australia: Annual Surveillance Annual Australia: in Infections Transmissible Sexually and C Hepatitis Guidelines: Health Risks and Benefits and Risks Health Guidelines: Setting Report , NCHECR,Sydney. , RACGP,Melbourne. , 4 th edn.,(DSM–IV),APA, Washington DC. , Drug Statistics Series No. StatisticsSeries , Drug 7,AIHW, Canberra. , DrugStatisticsSeriesNo.9,AIHWcat.no.PHE35,AIHW, Chapter 1 Investing in Drug and Alcohol Treatment Alcohol and Drug in Investing , CommonwealthDepartmentofHealthandAgeing,Canberra. Sydney, . , National Drug AndAlcoholResearch CentreMonograph , NationalDrug The Quantification of Drug-caused Mortality and Morbidity and Mortality Drug-caused of Quantification The Counting the Cost: Estimates of the Social Costs of Drug of Costs Social the of Estimates Cost: the Counting NationalAlcoholIndicatorsProject,BulletinNo. 3., www.ndarc.med.unsw.edu.au. Addiction , CommonwealthofAustralia,Canberra. Diagnostic and Statistical Manual of Mental of Manual Statistical and Diagnostic , vol. 96,pp. 677–678. 2001 National Drug Strategy Household Strategy Drug National 2001 How Many Dependent Opioid Dependent Many How , NationalDrugand Australian Alcohol Australian Patterns of Alcohol of Patterns Putting Prevention Putting HIV/AIDS, 15

Overview Introduction Overview Introduction

16 Chapter 2

General Principles of Management and Intervention

HIS CHAPTER reviews key principles involved in identification, management and intervention of alcohol and other T drug (AOD) problems. Issues covered here are expanded on in relevant chapters.

Problems associated with the use of alcohol or other drugs can General Principles be related to: intoxication regular use dependence

Not all problems are related to dependence or addiction. Many problems are related to non-dependent patterns of use that are risky for either the person or those around them. Interventions should be tailored to the type of problems experienced or the nature of the risks to which the individual is exposed.

HARM MINIMISATION

Harm minimisation is an important principle in the management and intervention of AOD problems. Many intervention options are pragmatic in nature and based on an understanding that changing behaviour can be a lengthy, complex process. From a harm minimisation perspective abstinence may not be the highest or most immediate priority: Emphasis is placed on reducing as many prob-

17 lems as possible associated with alcohol and Reasons include: drug use, and not just focusing on the drug

use per se. Harm minimisation strategies ad- not knowing what to look for dress the overall health and wellbeing of the lack of vigilance individual and the community at large. embarrassment about asking questions not knowing what to do if a problem is uncovered EFFICACY OF TREATMENT the person’s denial or evasion (Edwards, Marshall and Cook, 1997) It is important to stress the efficacy of treatments specific to problematic AOD use. In Detection rates can be improved by: contrast to common perceptions, there is a

range of effective, empirically evaluated routine enquiry about alcohol and drug use treatment options available. Treatment can screening questionnaires be successful. It is as successful as many biological screening (pathology tests) general medical treatments that are held in knowledge of common clinical presentations high regard.

Intervention earlier rather than later is strongly recommended. Treatment for long-term ROUTINE ENQUIRY ABOUT chronic problems can also be very effective. ALCOHOL AND DRUG USE

Table 2–1 General practice and primary health care General Principles Treatment success for dependence offer a variety of opportunities to enquire about alcohol and drug use; for example, in Drug of Success Rate the context of: Dependence (%) new patients — as part of initial informa- Alcohol 50 (40-70) tion gathering

Opioids 60 (50-80) management of chronic problems — alcohol for example, is a risk factor in car- Cocaine 55 (50-60) diovascular disease, diabetes, depression Nicotine 30 (20-40) management of acute problems, especially trauma, gastrointestinal disorders, anxiety/stress, psychological problems

Source: O’Brien and McLellan (1996) preoperative assessment pre-conception and antenatal care EARLY RECOGNITION enhanced Primary Care Medicare Benefit Schedule items — health assessment, AND SCREENING care plans and case conferences

Early recognition is important as it can en- Screening Questionnaires able intervention to occur before dependence or irreversible damage has developed. How- Use of general questionnaires covering life- ever, alcohol and drug problems can be diffi- style issues such as smoking, diet, exercise, cult to detect, especially in the early stages. alcohol and drug use may be less threaten-

18 Chapter 2

ing and stigmatising for patients. dermatological genito-urinary systems There is also a number of short, well vali- accidents/trauma, social and legal incidents dated questionnaires which can be used to screen for alcohol problems. Screening and Indicators of problematic drug use can in- brief interventions can readily be combined in a single general practice consultation. clude: infections (injecting users) accidents/trauma See Chapter 13 Psychosocial Interventions psychiatric problems behavioural, social and legal incidents Biological Screening See Chapters 3–12 for more A number of blood tests can be used to screen detail about individual drugs for alcohol problems. However, they can be less sensitive and specific than questionnaires. These screening tests include: Assessment full blood count, including MCV Assessment is critical and has several purposes: liver function tests, including gamma GT triglycerides to identify substance use behaviour early to discover the extent of use and its health

Urine testing can detect alcohol, other drugs effects General Principles (e.g. cocaine, opioids cannabis, to examine the social context of sub- benzodiazepines and barbiturates) and/or stance use in both the patient and sig- their metabolites. nificant others to determine a care plan and appropriate Screening tests for drug use include: interventions full blood count, including white cell count (Rassool, 1998) liver function tests hepatitis B and C and HIV serology The assessment phase should fulfil four important functions: COMMON CLINICAL 1. developing a therapeutic relationship PRESENTATIONS based on trust, empathy and a non-judgmental attitude Indicators of alcohol- or drug-related problems 2. helping the client to accurately reappraise are wide-ranging and can involve: their drug use, which may in turn facilitate cardiovascular the desire to change gastrointestinal 3. facilitating a review of the client’s past and present circumstances and linking these

musculoskeletal to current drug use

neurological 4. encouraging the client to reflect on the

19 choices and consequences of drug using Brief interventions are particularly suitable for behaviour primary care but can also be used in emergency (Helfgott, 1997) departments, hospital wards or outpatient clinics and a range of non-medical settings. Traditionally treatment success was meas- They are recommended for individuals with: ured by abstinence. Today there is more

emphasis on the client’s: hazardous/harmful alcohol use without dependence

wellbeing a low to moderate dependence on alcohol

beliefs about drinking and drug use a dependence on nicotine

readiness to change a low to moderate dependence on cannabis

alcohol- and drug-related expectancies (Best Practice in Alcohol and Other Drug In- social functioning and social support terventions Working Group, 2000).

These are all important predictors of success. There is compelling evidence for the effectiveness of brief interventions to reduce haz- Current approaches to treatment of alcohol- ardous and harmful alcohol consumption by and drug-related problems reflect a continuum 30–40% (WHO Brief Intervention Study of treatment. Group, 1996).

Brief interventions are not considered suitable MANAGEMENT OF for: General Principles LOW LEVEL PROBLEMS more complex patients with additional psychological/psychiatric issues

Low level drug and alcohol problems are much patients with severe dependence more common than dependence and are patients with poor literacy skills major causes of morbidity and mortality. Indi- patients with difficulties related to cogni- viduals with low level problems are better tive impairment suited to brief and early interventions whereas individuals experiencing more severe prob- In these instances, more in-depth interven- lems need more specialised treatment (Na- tion is recommended (Heather, 1995). tional Expert Advisory Committee on Alcohol, 2001). Brief intervention can take a variety of forms A ‘brief intervention’ is considered to be: but often includes:

‘any intervention that involves a minimum brief assessment of professional time in an attempt to self-help materials change drug use… Any intervention re- information on safe levels of consumption quiring a total of between five minutes and advice on reducing consumption two hours’ harm reduction (Heather, 1990) relapse prevention assessment of readiness to change, in-

20 Chapter 2

cluding motivational interviewing lored to the individual patient/client, taking brief counselling, including problem solv- into consideration such factors as culture, ing and goal setting age, gender and presence of comorbidity. follow-up General counselling should include: Six therapeutic elements are common to suc- linking patients with the appropriate serv- cessful brief interventions (FRAMES): ices while the patient is still engaged

F. Feedback — provide feedback from your anticipating and developing strategies clinical assessment with the patient to cope with difficulties before they arise R. Responsibility — emphasise the person’s

personal responsibility for their drug use specific evidence-based interventions and associated behaviour where appropriate (e.g. goal setting, cognitive behavioural therapy, motivational A. Advice — provide clear, practical advice enhancement therapy, problem solving) and self-help material focusing on positive internal and external M. Menu — offer a range of behaviour change resources and successes as well as prob- and intervention options lems and disabilities E. Empathy — express non-judgmental em- consideration of the wider picture and pathy and support helping the patient on a practical level S. Self-efficiency — stress belief in the per- (e.g. with food, finances, housing) son’s capacity for change where appropriate, involving key support- (Miller and Sanchez, 1993) ive others to improve the possibility of be-

havioural change outside the therapeutic General Principles environment See Chapter 13 Psychosocial Interventions (Best Practice in Alcohol and Other Drug In- terventions Working Group, 2000) Psychosocial Interventions Mutual aid groups such as Alcoholics Anony- Psychological interventions are a key com- mous, Narcotics Anonymous, Al-Anon (for ponent of a comprehensive treatment program relatives of alcohol dependent individuals) and and can involve group therapy or individual Alateen (for adolescent relatives) are also counselling. available. Their approaches are based on the 12 Steps, a set of principles that emphasise ‘…counselling alone is not usually suffi- personal responsibility and honesty. cient to change the drug taking behaviour of most clients’

(Jarvis et al., 1995) MAINTENANCE PHARMACOTHERAPIES Counselling is a joint approach between the counsellor and the client with treatment plans A number of effective therapeutic drugs are negotiated and agreed upon by both parties. now available for the treatment of dependence, No single psychological approach is supe- primarily for alcohol, nicotine and opioid de- rior, and the treatment program should be tai-

21 pendence. It is likely that the use of pharma- ment program. cotherapies will increase in the future. Disulfiram (Antabuse®) Pharmacotherapies should not be considered as stand alone treatments but should be used An alcohol-sensitising agent which inhibits as part of a comprehensive treatment pro- aldehyde dehydrogenase causing a toxic gram, including supportive counselling, other build-up of acetaldehyde if alcohol is con- relevant therapies and social support. sumed. This results in unpleasant symptoms such as facial flushing, nausea, vomiting, sweating and palpitations.

PHARMACOTHERAPIES FOR Randomised controlled trials have shown ALCOHOL DEPENDENCE variable results and only a modest effect in promoting abstinence. Disulfiram is not avail- Acamprosate (Campral®) able on the PBS. This is an anticraving agent which acts as a GABA-receptor agonist. Randomised control- PHARMACOTHERAPIES led trials have shown: FOR OPIOID DEPENDENCE reduced quantity and frequency of drinking in patients who do not achieve complete abstinence Buprenorphine reduced rates of relapse (where relapse A strong opioid analgesic with both partial

General Principles is defined as consumption of any alcohol) agonist and partial antagonist properties. It is increased percentages of abstinent days an alternative to methadone for withdrawal during treatment and maintenance treatment, and has a much lower risk of death from overdose than metha-

increased rates of abstinence done. Buprenorphine is listed on the PBS as S100 under Section 100 of the National Health Naltrexone (Revia®) Act 1953 and is approved by the Therapeutic Goods Administration (TGA). This anticraving agent is a competitive opioid antagonist which blocks the euphoric and reinforcing effects of alcohol. Methadone Randomised controlled trials have shown: This is a long-acting synthetic opioid which can be used for both withdrawal and mainte- reductions in the amount and frequency nance treatment. It decreases the need for of drinking overall heroin-dependent individuals to regularly use

reductions in the rate and relapse into intravenous opioids. Methadone mainte- heavy drinking (where relapse is defined nance programs monitor drug use and should as a return to > 5 drinks per day) provide ongoing counselling and support. increased rates of alcohol abstinence Methadone is listed on the PBS as S100 under Section 100 of the National Health Act Both naltrexone and acamprosate are avail- 1953 and is approved by the Therapeutic able on the Pharmaceutical Benefits Scheme Goods Administration (TGA). (PBS) for use within a comprehensive treat-

22 Chapter 2

Levoalphaacetylmethadol Home-based withdrawal management (LAAM) should be considered: LAAM is a synthetic opioid analgesic which when there is no evidence of severe with- acts similarly to methadone. It is long-acting drawal, e.g. tremor, hallucinations, disori- and only needs to be taken three times per entation* week. Overseas trials suggest that LAAM is where there is no past history of delirium as safe as methadone and has similar treat- tremens or of fits* ment outcomes and patient retention. This in the presence of supportive relatives who drug is not available for use in Australia. elect to stay with the patient during the period of detoxification Naltrexone (Revia®) when there is no evidence of a medical This is a competitive opioid antagonist, which illness such as pneumonia or pancreati- completely blocks the effects of opioids for tis* 24 to 72 hours. Maintenance therapy is suit- when no previous history or evidence of able for highly motivated patients who wish suicide is contemplated to remain abstinent, are socially and psycho- where the patient does not have access logically stable and have good social sup- to the drug from which they are being with- port. Naltrexone is not listed on the PBS for drawn opioid dependence but is approved by the (* in the case of alcohol) TGA as an adjunctive therapy. Clinical trials are also underway using naltrexone for rapid detoxification. Withdrawal can be medicated (assisted by the use of controlled sedatives) or non-medicated.

The latter is appropriate for patients who have General Principles no co-existing medical disorders and when WITHDRAWAL AND only a mild withdrawal can be anticipated. DETOXIFICATION In cases of multiple drug use, patients may not Detoxification is withdrawal from a drug in a wish to withdraw from all substances at the supervised way in order to minimise withdrawal same time. Withdrawal management should be symptoms and risks related to withdrawal. part of an ongoing treatment program linked to coping and relapse prevention strategies.

Details of withdrawal management are covered in the management and intervention sections of relevant chapters on specific drugs. INTOXICATION AND OVERDOSE Effective withdrawal management may be performed in the home supported by the GP, Intoxication is defined as the intake of a other health workers and non-using supportive quantity of a substance which exceeds the relatives or friends. This form of withdrawal individual’s tolerance. management depends on: the drug of dependence Further reading: the severity of the dependency Ellenhorn & Barceloux (1988) the wishes of the patient

23 Overdose is defined as the state that occurs when a person has ingested a quantity of a COEXISTING MENTAL drug that exceeds tolerance and produces HEALTH PROBLEMS behavioural and physical abnormalities. In patients using alcohol and other drugs co- Details of intoxication and overdose manage- existing mental health problems, such as anxi- ment are covered under the management and ety and depression, are not uncommon. It is intervention sections in each Chapter. important to distinguish symptoms which are: part of a primary psychiatric disorder When presented with an intoxicated or over-

dose patient the priority is ABC First Aid pro- secondary to problems such as marital conflict, homelessness or legal problems cedures: drug or alcohol induced A — Airway B — Breathing See Chapter 18 C — Circulation/cardiac Coexisting Mental Illness

In acute overdose it is recommended that patients are closely observed, monitored and referred to an acute hospital. DRUG SEEKING

Do not assume that alcohol or drugs are the Clinical Features sole cause of the patient’s coma. Other possi-

General Principles ble causes include: Patients seeking prescribed drugs for non- medical use often approach emergency departments of major hospitals or general practition- trauma ers’ surgeries at busy times or shortly before

epilepsy closing. Patients may choose a general prac- metabolic abnormalities – diabetes, he- titioner who does not know them or who are patic failure, hypercalcaemia, renal fail- known to prescribe drugs very readily. ure cerebrovascular events – cerebral haem- Drug seeking patients are usually: orrhage/thrombosis, abscess, tumour polydrug using cardiovascular events – arrhythmias,

myocardial infarction males

respiratory failure aged in their twenties or thirties infection – meningitis, encephalitis The drugs sought are usually: Once intoxication or overdose has been opioid analgesics; or treated it is important to: benzodiazepines

ask about depression, suicidal ideation The presentations for analgesics usually in- (may need a referral to a psychiatrist) volve painful conditions where there are few explore withdrawal management and physical signs, such as headache, renal colic treatment options

24 Chapter 2

or backache. The names of analgesics which Presentations for benzodiazepines often in- have proved effective on previous occasions volve a history of anxiety or insomnia due to are often referred to with familiarity. a recent bereavement. Short-acting benzodiazepines should only be prescribed The most frequently requested opioid is in very special circumstances and then only pethidine by injection. in small quantities. If benzodiazepines have to be prescribed, it is better to select long- acting forms but in small quantities. Commonly, patients will claim that analgesics other than the preferred type: Doctors who consider that a patient is seek- have previously proved ineffective and/or ing drugs should gently advise the patient that resulted in severe side effects including they are concerned about this possibility and an allergic reaction. offer relevant assistance or referral.

A careful history plus physical examination contributes substantially to the diagnosis and GENERAL MANAGEMENT management plan. Suspicion of illicit drug use APPROACHES is supported by a history of common complications of drug use (such as hepatitis C, endocarditis or previous incarceration). Physical Support and treatment for drug users should examination should include inspection for follow the general supportive and common- track marks. It is often helpful to have a pa- sense approaches described below. tient discretely observed by an experienced nurse for signs of variability in the severity of Clinicians should: signs of pain. General Principles not judge the user and should not insist on abstinence Management seek to engage and retain the user in treat- As special tests usually cannot prove if the ment for as long as possible, as retention patient’s symptoms result from organic dis- is associated with better outcomes ease, the final clinical decision depends on (Simpson et al., 1999) the doctor’s judgment and experience. In most ensure understanding of the client/pa- cases, decisions are relatively easy. When tient’s treatment goals: uncertain, the choice has to be made between " to make it through an acute crisis? possibly withholding analgesia from a patient in severe pain or possibly prescribing an opioid " to reduce frequency and/or quantity of analgesic to a malingering patient. The former drug use? is a far more serious error. " to achieve long-term abstinence?

Injections of ketorolac (Toradol®), a non- tailor the treatment where possible to steroidal anti-inflammatory drug (NSAID), is meet those goals, including referral when a safe way of providing a potent analgesic appropriate to: without prescribing an opioid. " treatment programs " individual counsellors Buprenorphine is a potent analgesic which " family counsellors provides minimal euphoria but this can precipitate opioid withdrawal if the patient has " self-help groups such as NA withheld a history of recent opioid use.

25 remember the need for flexibility of service delivery; as goals and outcomes change throughout the course of treatment, the treatment program should be adjusted to reflect these changes provide as multifaceted and intensive a program as possible, as more intensive psychosocial treatment programs are associated with better outcomes (Crits- Cristoph, 1999).

Readiness to Change In patients who do not wish to become abstinent despite significant impairment related to drug use, the clinician should attempt to: establish an empathetic, respectful relationship retain contact with the client maximise physical and mental health, as clients will find it difficult to achieve long- term abstinence if chronic medical problems have not been adequately treated General Principles enhance motivation toward abstinence by educating clients and their significant others about the usual course of drug dependence and the relationship between drug use and current and/or future problems emphasise the client’s responsibility for their own actions help clients rebuild a life without drugs through: " vocational counselling " family counselling " helping them build a network of non- drug using peers " showing them how to use free time appropriately

26 Chapter 2

RESOURCES

Further reading: A basic modern text on toxicology is Ellenhorn, M. & Barceloux, D.G. (1988), Medical Toxicology: Diagnosis and Treatment of Human Poisonings, Elsevier, New York.

REFERENCES

Best Practice in Alcohol and Other Drug Interventions Working Group 2000, Evidence Based Practice Indicators for Alcohol and Other Drug Interventions, www.wa.gov.au/drugwestaus

Crits-Cristoph, P. 1999, ‘Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study’, Archives of General Psychiatry, vol. 56, pp. 493–502.

Edwards, G., Marshall, E.J. & Cook, C.C.H. 1997, The Treatment of Drinking Problems: A Guide for the Helping Professions, Cambridge University Press, New York.

Heather, N. 1990, cited in Ali, R., Miller, M. & Cormack, S. 1992, Future Directions for Alcohol and Other Drug Treatment in Australia, AGPS, Canberra.

Heather, N. 1995, ‘Psychology and brief interventions’, British Journal of Addiction, vol. 84, pp. 357–370 General Principles

Helfgott, S. 1997, ‘Assessment’ in Helfgott, S., (ed.), Helping Change: The Addiction Counsellor’s Training Program. Western Australian Alcohol and Drug Authority, Perth.

Rassool, G. Hussein (ed.) 1998, Substance Use and Misuse: Nature, Context and Clinical Interventions, Blackwell Science, Oxford.

Jarvis, T.R., Tebbutt, J. & Mattick R.P. 1995, Treatment Approaches for Alcohol and Drug Dependence. An Introductory Guide, John Wiley & Sons Ltd., Chichester, England.

Miller, W.R. & Sanchez M.C. 1993, ‘Motivating young adults for treatment and lifestyle change’ cited in Howard, G. (ed.), Issues in Alcohol Misuse by Young Adults University of Notre Dame Press, Notre Dame, pp. 55–79.

National Expert Advisory Committee on Alcohol 2001, National Alcohol Strategy. A Plan for Action 2001 to 2003–04, Commonwealth Department of Health and Aged Care, Canberra.

O’Brien, C.P. & McLellan, A.T. 1996, ‘Myths about the treatment of addiction’, Lancet, vol. 347, pp. 237–240.

27 Simpson, D.D., Joe, G.W., Fletcher, B.W., Hubbard, R.L. & Anglin, M.D. 1999, ‘A national evaluation of treatment outcomes for cocaine dependence’, Archives of General Psychiatry, vol. 56, pp. 507–514.

WHO Brief Intervention Study Group 1996, ‘A Cross-national trial of Brief Interventions with Heavy Drinkers’, American Journal of Public Health, vol. 86, pp. 948–955. General Principles

28 Part 2

The Drugs

29 30 Chapter 3

Alcohol Alcohol

LCOHOL is a licit drug. Its consumption is sanctioned by cultural norms and social practices, and its production A contributes significantly to Australia’s gross national product (GNP).

Alcohol is a central nervous system (CNS) depressant. Its psychoactive properties contribute to changes in mood, cognition and behaviour. The main psychoactive ingredient in beverage

alcohol is ethyl alcohol (ethanol, or C2H5OH).

PHARMACOLOGY

Absorption Alcohol is rapidly absorbed from the small bowel via portal circulation (around 80%), and stomach (around 20%). Alcohol is water soluble, and little or no alcohol enters fatty tissue. It reaches the brain within five minutes of ingestion, with blood concentrations peaking between 30 to 90 (typically 45) minutes. Absorption rate varies with:

the drug (e.g. beverage type, presence of food in the stomach) individual factors (e.g. age, gender, size, drinking rate and experience)

31 Distribution Contrary to common perceptions, Aboriginal and Torres Strait Islanders: Alcohol is rapidly distributed throughout the body water accumulating in tissues with high are more likely to be non-drinkers or ex- water content. Alcohol readily crosses drinkers blood–brain and placental barriers (Lopatko are less likely to drink on a weekly (33% com- et al., 2002). pared with 49% of the general population) or occasional (29% versus 32%) basis; and Alcohol Metabolism are more likely to drink at high or very high risk levels on the occasions they do drink Ninety-five per cent of alcohol is metabolised alcohol (82% versus 28%), compared to by the liver into carbon dioxide and water, and the general population (CDHAC, 2001; 1–5% is excreted unchanged in saliva, urine, CDHSH, 1994; NHMRC, 2001) faeces and sweat. The enzyme alcohol dehydrogenase (ADH) (and to a smaller extent, cytochrome P450 2E1 (or CYP2E1)) is the catalytic agent for transforming ethyl alcohol BENEFITS AND HARMS into acetaldehyde. The second metabolic process involves aldehyde dehydrogenase (ADLH) as the catalytic agent responsible for oxidis- Benefits ing acetaldehyde into acetic acid. Long-term There is good evidence that < 1 standard drink high-risk consumption results in increased pro- a day for women, and 1–2 a day for men helps duction and activity of CYP2E1, thought to be prevent heart disease from middle age on- responsible for increasing elimination of alco- wards. The benefit is attributable to alcohol per hol amongst high-risk/dependent users (Vic- se, rather than the beverage type consumed. toria Police, 2001; Lopatko et al., 2002). Heavier drinking not only confers no additional benefit, but substantially increases risk of harm. Cardiac protection needs to be assessed PATTERNS OF DRINKING against the physiological changes of ageing (e.g. reduced tolerance to alcohol’s effects, interaction with prescribed medications). Any Results from the 2001 National Household benefits can be equally achieved through a Survey (AIHW, 2002) of adults 14 years and healthy lifestyle. There is no evidence that low over found: risk drinking in younger adulthood helps prevent the onset of cardiovascular disease in 8.3% (M: 11%; F: 5.6%) reported drinking later life (NHRMC, 2001). alcohol on a daily basis almost 40% (M: 46%; F: 33%) consumed alcohol at least once a week Harms 35% (M: 29%; F: 40%) consumed alcohol Most drinkers (73%) generally consume less often than once a week alcohol in ways considered a low health risk 8% (M: 7%; F: 9%) were ex-drinkers (AIHW, 2002). However, harmful/hazardous alcohol use and dependence is estimated to

almost 10% (M: 7%; F: 12%) had never cost the Australian community $7.6 billion in drunk a full glass of alcohol direct and indirect costs (Collins & Lapsley, 90% of 20–29 year olds were current 2002). Single episodes of alcohol intoxication drinkers contribute to 67% of potential years of life lost (PYLL) due to premature alcohol- related mortality (CDHAC, 2001).

32 Chapter 3

Alcohol contributes to over 3,000 deaths per females: consume 4 drinks or less on year, and is implicated in: any one occasion, or no more than two standard drinks per day, with at least 2

7% of all male and 2% of all female deaths alcohol free days per week

50,000 hospitalisations Abstinence is recommended as appropriate 20–40% of acute general and psychiatric for: hospital presentations people with an existing medical or men- 18% of all injuries presenting to emergency Alcohol tal health condition that may be exacer- departments bated through drinking 50% of assaults people taking medications that interact with 44% of fire injuries alcohol (e.g. benzodiazepines, opioids) 34% of falls and drownings women who are pregnant, planning a 30% of car accidents pregnancy, or breastfeeding 16% of child abuse people undertaking activities involving skill 12% of suicides; and or risk (e.g. operating machinery, driving, flying, water sports etc.) 10% of industrial accidents (CDHAC, 2001; CDHA, 2002; NHMRC, 2001; N.B. Levels of risk related to the use of alcohol APF, 2001) are based on an average or larger body size and a weight of 50 kg or more (NHMRC, 2001). Studies suggest that 15–32% of patients presenting to general practice drink at at-risk levels (Sayer et al., 2000). However, fewer than EFFECTS OF half of all patients routinely undergo screening for alcohol use (Lopatko et al., 2002). ALCOHOL CONSUMPTION

The Australian Alcohol Guidelines: Health Blood Alcohol Concentration (BAC) is a rea- Risks and Benefits (NHMRC, 2001, sonable guide to level of intoxication (see www.nhmrc.gov.au) provide an evidence base Table 3–1). BAC indicates the amount of al- for promoting individual and population cohol in the bloodstream in grams of alco- health in relation to alcohol consumption. The hol per 100 ml blood. A BAC of 0.05 means guidelines emphasise the link between ‘how a person has 0.05 g of alcohol per 100 ml of much’ and ‘how often’ alcohol is consumed, blood (or a BAC of 0.05% = 11 mmol / L) where the risks are described according to (Victoria Police, 2001). A person of average three levels (low, risky and high risk), and build will metabolise alcohol at a constant two timeframes (short-term and long-term). rate of around one standard drink per hour. One standard drink (see Table 3–2) per hour See Appendix A will cause a rise in BAC of 0.01% to 0.02% in an hour; however: The NHMRC Australian Alcohol Guidelines small females will have higher blood peak recommend that to minimise harm: levels than large males for the same volume consumed males: consume 6 drinks or less on any high tolerance to alcohol may result in one occasion, or no more than 4 stand- faster metabolism (hence more rapid re- ard drinks per day, with at least 2 alcohol duction in BAC) free days per week

33 Table 3–1 Correlation between BAC* and behavioural/motor impairment

BAC* Likely effects of intoxication 0.02–0.05 g / 100 ml • cheerful, relaxed, pleasant feelings of happiness and wellbeing

Alcohol • decreasing inhibitions • judgment increasingly impaired • increased chance of accidents • impaired coordination • BAC* 0.05 g / 100 ml = legal limit for driving (if fully licensed) in all Australian States and Territories

0.1–0.2 g / 100 ml • ataxia • decreased ability to appropriately interpret and react to surroundings • poor judgment • loss of ‘self-control’ • slurred speech • increasingly unpredictable behaviour • labile mood • potential for aggression

0.2–0.3 g / 100 ml • marked ataxia and slurred speech • poor judgment • labile mood • nausea and vomiting • double vision • memory loss

0.3–0.4 g / 100 ml • stage 1 anaesthesia (sleepiness, poor response to external stimuli, oblivion) • memory lapse • labile mood

> 0.40 g / 100 ml • respiratory failure • coma • possible death

*Blood Alcohol Concentration Source: adapted from Victoria Police (2001, p. 1.8) and Ryder et al. (2001, p. 162).

34 Chapter 3

MEASURING Groups at High Risk for CONSUMPTION: Alcohol-related Harm THE ‘STANDARD DRINK’ The NHMRC (2001) identified groups who are particularly susceptible to alcohol-related The ‘standard drink’ concept was designed harm, including: to assist consumers to monitor their alcohol

consumption. One Australian ‘standard drink’ Young people (up to 18 years) and Alcohol contains about 10 grams (12.5 millilitres) of young adults (19–25 years) alcohol. See Table 3–2 for common stand- Young people’s patterns and levels of drinking ard drink equivalents. Whilst legislation re- place them at significant risk of harm compared quires alcohol producers to label the number with the community in general. Whilst alcohol- of standard drinks in a container, variation in size and type of glass in different environments related deaths amongst older people can be (e.g. homes, licensed environments) may attributed to long-term hazardous or harmful make it difficult to estimate the actual number patters of use (Chikritzhs et al., 1999), ap- of drinks consumed. proximately 25–33% of 14–24 year olds drink in a high-risk manner (Chikritzhs et al., 2000), Identifying ‘At-risk’ increasing the likelihood of serious harm, in- Drinking Levels jury or death due to acute conditions resulting from alcohol intoxication. Between 1990 Most people tend to be low-risk drinkers, and and 1997, 52% of all serious alcohol-related experience few problems related to their use of road injuries were sustained by people aged alcohol, most of the time (see Figure 3–1). 15–24, with a further 23% of injuries sustained by 25–34 year olds.

3%3% Risk of harm amongst young people is in- 7% 17% 7% 17% creased due to their: smaller physical size fewer social controls peer values and norms that condone intoxicated behaviour risk of overdose due to lack of tolerance

Use of alcohol or other drugs at risky and harmful levels may:

73% interfere with normal physiological, social 73% and emotional development increase risk of suicide increase risky sexual behaviour/unwanted sex cause blackouts Figure 3–1 contribute to poor academic performance Proportion of population at risk of contribute to, or cause mental health alcohol-related harm problems Source: AIHW (2002)

35 Table 3–2 Standard drink (SD) equivalents

Beverage Container % alc/vol Standard Drink equivalent BEER Alcohol Light 375 ml can or bottle 2.7% 0.8 Mid strength 375 ml can or bottle 3.5% 1.0 Full strength 375 ml can or bottle 4.5% 1.5 Light 285 ml glass 2.7% 0.5 (middy/pot/schooner) Mid strength 285 ml glass 3.5% 0.7 (middy/pot/schooner) Full strength 285 ml glass 4.5% 1.0 (middy/pot/schooner)

WINE White/red 100 ml glass 12% 1.0 180 ml average 12% 1.8 restaurant serve 12% 7.0 750 ml bottle 12% 20.0 2 litre cask 12% 40.0 4 litre cask 4.7–7.5% 1.4–2.0 Cider 375 ml bottle/stubbie 2.8–4.0 750 ml bottle

FORTIFIED WINES E.g. port, sherry 60 ml glass 21% 1.0 750 ml bottle 18% 11.0 2 litre (cask/flagon) 18% 28.0

PREMIX COOLERS 340 ml bottle AND SODAS 375 ml can 5–8% 1.5–2.4 250 ml–350 ml bottles 3.5–5.5% 0.7–1.4

SPIRITS 30 ml (nip) 42% 1.0 700 ml bottle 40% 22.1

Source: adapted from ATODS (1997) and NHMRC (2001). Note: a 285 ml glass is a ‘middy’ in NSW, WA and ACT; a ‘pot’ in TAS; a ‘handle’ in NT; and a ‘schooner’ in SA.

36 Chapter 3

cause behavioural problems, such as childhood problem behaviours related to fighting, resulting from feelings of aggres- impulse control sion (NHMRC, 2001) poor coping responses in the face of stressful life events People with mental health problems depression, divorce or separation The psychoactive effects of alcohol can re- having a drinking partner and working in sult in exacerbation of existing mental health a male dominated environment problems. Alcohol may also interact with pre- Alcohol scribed medications. Always give specific Although women enter treatment at about advice to avoid alcohol where it is contra- half the rate of men, treatment outcomes are indicated. similar. Attitudes towards women drinkers, depression, concerns about children, or fear Unborn children of removal of children are potent barriers to The foetus is most vulnerable to damage seeking treatment (NHMRC, 2001). from high-risk drinking during the first few weeks after conception. Drinking above the Occupational groups low-risk guidelines can contribute to adverse Workers in some occupational groups engage outcomes for the baby (e.g. foetal death, growth retardation, behavioural deficits, con- in risky or harmful drinking patterns more genital malformations). However, there is ‘no often than others due to a range of social and discernible evidence’ that one standard drink environmental factors. a day causes harm to an unborn child These groups may include: (NHMRC, 2001). trades (e.g. building, mining, construction, Women forestry, transport, fishing)

Women are more susceptible to alcohol-related hospitality industry harms due to: women employed as specialist managers (finance, personnel, public policy, sales) their reduced ability to metabolise alcohol transport, publishing, wholesale and relative to males service industries (e.g. entertainment)

physical makeup (smaller body frame, (NHMRC, 2001) liver, higher proportion of body fat, different biochemical processes relative to males (Litt et al., 1993)). Women are likely to develop complications earlier, IDENTIFYING HARMS and are more vulnerable to liver damage and cirrhosis at lower consumption lev- As with other drugs, alcohol-related harms els. High consumption is related to breast are not specific to the effects of the drug. cancer Alcohol-related harms result from the inter- environmental influences which place action between: women at greater risk of intoxication- related harms (e.g. assault and injury) The drug patterns of use (how much, when used, Risk factors for hazardous and harmful drinking how often) patterns in women include: and other drugs used a positive family history

37 The individual The environment age, weight, gender and general health Factors that influence the drug’s effects and tolerance and previous experience of patterns of use such as: alcohol use, intoxication, after effects social settings and company and withdrawal context of use expectations of use and effects

patterns of drug use according to ritual or

Alcohol current mood and psychological health culture

Table 3–3 Classification of alcohol-related harms

Intoxication Regular Excessive Use Dependence Examples of • hangovers • irritability • cirrhosis problems • insomnia • depression • pancreatitis • reduced work • anxiety • oesophageal performance • altered sleep patterns varices • • road and • hypertension peripheral industrial neuritis • weight gain accidents • tolerance • • gastritis unintended • withdrawal • unsafe sexual impotence symptoms practices • fatty liver • anxiety • violence • memory loss • depression • financial issues

Consumption In a single session: Standard drinks / day Standard patterns • > 6 standard • see NHMRC drinks / day drinks (male) guidelines for short- • male > 10 • > 4 or more and long-term harms • female > 8 standard drinks (Appendix A) (female)

Prevalence Common Risky / harmful Relatively • 10–15%, • 10–20% population uncommon especially in • < 5% males adolescence and • < 2% females early 20s

Source: Thorley (1980) adapted by Litt et al. (1993, p. 5)

38 Chapter 3

Thorley’s model (see Table 3–3) is a useful Four Key Assessment Steps guide to identifying specific harms related to 1. Establish patterns of use ‘Intoxication’, ‘Regular Excessive Use’ and ‘Dependence’. This model enables practition- Techniques for incorporating use of alcohol ers to: into history taking include:

assess the type of problem incorporating questions about general lifestyle issues, such as smoking, diet,

Alcohol assess severity of problems exercise, recreational activities

facilitate individually tailored responses asking specific questions (type of drug/s, dose, frequency of use, duration of use, General points: recency of use, how used) focusing on the current week’s patterns

intoxication-related problems have sub- use of a visual Standard Drinks Chart stantially greater impact on the community (e.g. www.dasc.sa.gov.au), (see Table 3–2) than dependence, however, dependence

results in more severe problems for indi- asking about concurrent use of other viduals drugs, e.g. tobacco, amphetamines, benzodiazepines, heroin regular use is not generally considered a problem unless it exceeds the ‘at-risk’ thresholds described by the NHMRC These strategies help prevent patients from (2001) giving general responses such as ‘I only drink primary care practitioners are likely to have socially’. Conversation starters might include: most success in their interventions with ‘Now that we have dealt with…(presenting people experiencing problems related to complaint)…let’s have a look at other areas intoxication and regular use that may contribute to your health. Are you patients experiencing problems related to allergic to anything? Do you smoke? When dependence are best referred to special- did you last have a drink?’ ist agencies ‘We often find that eating, smoking and drinking habits affect our health. I’d like to ask ALCOHOL ASSESSMENT you a few questions about these things.’

Assume the patient consumes alcohol to Early Recognition of some degree, so introduce drinking as a nor- Alcohol-related Problems mal practice, for example: Alcohol-related problems are more likely to be ‘Most of us like to have a drink. How often identified early when the health professional: would you have a drink during the week is aware that psychosocial problems oc- and at the weekends?’ cur before most physical problems is willing to follow up with detailed en- ‘Did you have a drink yesterday? What did quiry and appropriate investigations you have, where were you, and how long were you drinking?’ www.health.gov.au/pubhlth/ publicat/document/ (Adapted from the APF, 2001 and Litt et al., alcproblems.pdf 1993)

39 Additional aspects of a drinking history signs indicative of poor functioning, e.g. should include: poor general appearance, poor hygiene repeated admissions for possible alcohol- pattern of consumption over past 7 days, related conditions commencing with today, and working backwards peripheral neuropathy establishing pattern over a ‘typical week’, cerebellar ataxia (broad based gait) including alcohol use during special events

Alcohol cognitive dysfunction (impaired mini- (e.g. anniversaries, celebrations) mental examination) determining whether alcohol consumption past history (withdrawal and treatment his- is related to cultural/religious practices/ tory, periods of abstinence) beliefs indicators from relevant pathology tests (NSW Health, 2000) 2. Establish risk Indicators of risk for alcohol-related harm in- See Appendix B clude:

health or social problems related to al- Use Figure 3–2 with patients as a tool for cohol use opening discussion about indicators of high concerns (self or family) about levels of risk drinking patterns, and how alcohol use consumption may be related to interpersonal, social, psy- concerns about consequences related to chological and general health problems. intoxication or high risk use, such as accidents, assaults, injuries, driving offences, 3. Identify problems associated embarrassment related to behaviour whilst with use intoxicated medical use of other drugs (alcohol may interact financial with or enhance the effects of other drugs) legal physical trauma, possibly attributable to

alcohol use employment

signs of intoxication or hangover relationships (social, work, family)

consumption regularly exceeding NHMRC violence guidelines for short-term high-risk use psychological and psychiatric anxiety, depression, sleeping difficulties sexual not otherwise explained 4. Match presentation to intervention Signs and symptoms suggestive of alcohol For appropriate matching of patient and in- dependence may include: tervention, consider: current intoxication (positive BAC, smell of the patient’s wants and needs alcohol on the breath, slurred speech, ‘stage of change’ ataxia) withdrawal symptoms (tremor, sweating, agitation, anxiety, increased blood pres- See Chapter 13 sure, pulse) Psychosocial Interventions signs of liver disease (hepatomegaly, spi- der naevi)

40 Chapter 3

type and severity of problems (physical, social, emotional), and links with problems related to intoxication, regular excessive use or dependence patient safety (including other health or social risks) (Alliance of NSW Divisions, 2000) Alcohol

Figure 3–2 Common effects of high-risk drinking Source: Babor, T., Higgins-Biddle, J.C. Saunders, J. & Monteiro, M.G. (2001)

41 SCREENING FOR Most laboratory measures are less sensitive ALCOHOL USE than good clinical judgment and self-report measures, such as AUDIT and CAGE, in detecting alcohol dependence and related Invasive Measures health care problems (Dawe et al., 2002). Estimating BAC (Blood Alcohol Concentration) See Appendix B

Alcohol A breathalyser is a reliable way to determine BAC. Breath analysis offers a good correlation between body burden of alcohol and concentra- Non-invasive Measures tion of alcohol in pulmonary blood circulation Detecting alcohol-related problems is more through measuring end-expiratory breath. Breath effective with the use of specific purpose analysis: screening tools. The screening tools most indicates recent consumption however, frequently used in Australia include: cannot identify patterns of high-risk or AUDIT harmful patterns of use CAGE is accurate, but expensive (a breathalyser unit needs to be purchased and regularly T-ACE calibrated) TWEAK results are available immediately (For information on T-ACE and TWEAK refer Note: The term Blood Alcohol Concentration to Dawe et al., 2002.) (BAC) may be used interchangeably with Blood Alcohol Level (BAL). CAGE The CAGE is a four item screening question- See www.dasc.sa.gov.au for the naire designed to identify problem or ‘at-risk’ ‘DRINKMETER Program’, an interactive guide drinking. for determining BAC after a ‘typical’ drinking session (taking into consideration age, height, It can be administered as part of an interview, weight etc.). or as a self-report measure, and has been successfully used across health settings, and Laboratory investigations across cultures with minor modifications (Dawe Use of laboratory tests may assist the practi- et al., 2002). The items are: tioner to relate drinking consequences with 1. Have you ever felt you ought to Cut down physical sequelae, and encourage the patient on your drinking? to think about their drinking. Whilst elevated 2. Have people Annoyed you by criticising biochemical markers may be indicative of liver your drinking? disease, most tests are neither sensitive or specific to both long-term or hazardous alco- 3. Have you ever felt bad or Guilty about your hol use. Liver function tests (LFTs) provide drinking? general information about the impact of alco- 4. Have you ever had a drink first thing in hol on the body. Carbohydrate deficient trans- the morning (Eye-opener) to steady your ferrin (CDT) tests are more sensitive and spe- nerves or get rid of a hangover? cific indicators of long-term high-risk use.

42 Chapter 3

Scoring ‘yes’ to two or more questions is pre- assist in informing the type of intervention dictive of current hazardous or harmful drink- that would be appropriate (e.g. strategies ing patterns, and indicates a need for further for a young person drinking infrequently but assessment. The CAGE has a sensitivity and at high-risk levels will be different to an in- specificity of 84% and 95% respectively, and tervention offered to an older person drink- a positive predictive value of 45% using a cut ing less, but more frequently) off of > 2 positive responses. But because indicate areas requiring further assessment

CAGE is considered insensitive to detection (e.g. where the patient is showing signs of Alcohol of low levels of problematic drinking the dependence) (refer to Dawe et al., 2002; AUDIT is considered the screening instrument Babor et al., 2001). of choice, given that little additional time is required to complete, score and interpret the AUDIT (Dawe et al., 2002). BRIEF INTERVENTIONS The AUDIT The AUDIT is a 10 item screening instrument Health professionals are well placed to: designed to identify hazardous and harmful identify alcohol-related harms, and prob- alcohol consumption as well as dependence. lems related to consumption or after ef- It is easy to use, short, and enables valuable fects of use patient feedback. The AUDIT is consistent with

ICD-10 definitions of harmful alcohol use and assist patients to link patterns of consump- dependence and focuses on recent use of al- tion with current lifestyle, social or health- cohol. It has been validated across countries, related problems cultures and languages (Babor & Higgins- provide specific, tailored interventions, Biddle, 2001; Dawe et al., 2002). that have demonstrated efficacy within a single, or short series of consultations. Administration of AUDIT The AUDIT can be administered as an inter- A brief intervention consisting of a short five view or as a self-report measure (see Babor minute session may incorporate: et al., 2001). identification of current patterns of use, linking consumption patterns with identi- See Appendices C & D fied problems identification of ‘stage of change’ Interpreting the AUDIT See Chapter 13 The 10 questions are each given a score of Psychosocial Interventions between 0 and 4, with a maximum overall score of 40. Whilst a single global score is assistance to assess pros and cons of cur- considered representative of overall drinking rent patterns of use behaviour, examination of individual re- motivational interviewing techniques sponses to each question are important, as advice on safe drinking guidelines and this will help: ways to cut down identify pattern of use (quantity and frequency of use, level of risk) See Appendix E

43 provision and explanation of self-help ma- " judgment terials e.g. drinking diaries " comprehension

relapse prevention strategies (if relevant) " mood " speech Brief interventions conducted over a short se- " perception (hallucinations) ries of 2–3 sessions tend to have an educa- tional focus, and may include:

Alcohol Complications of acute comprehensive assessment alcohol intoxication or overdose specific advice Possibly: counselling respiratory paralysis, particularly if vomit teaching goal setting strategies to assist is inhaled moderating drinking patterns or reducing obstructive sleep apnoea harms (Lopatko et al., 2002) fatal cardiac arrhythmia when blood alcohol is greater than 0.4 mg / ml See Chapter 13 Psychosocial Interventions Alcohol intoxication will only resolve with time. Management of intoxication depends on the Table 3–4 shows the FLAGS approach to al- location of the affected person, type of service cohol intervention using the AUDIT. available, and skills of the worker to monitor and observe for complications. Management includes: ALCOHOL INTOXICATION managing behaviours of affected person (e.g. don’t engage in discussion of emo- tive topics, diffuse aggressive behaviour) Acute Alcohol Intoxication provide a non-threatening and non-stimu- Intoxication may be recognised by: lating environment

ataxia and slurred speech encourage sleep

emotional lability and disinhibition observe for signs of other medical conditions that mimic intoxication (e.g. head

smell of alcohol on the breath injury, diabetes, infection, epilepsy, drug mood variations toxicity). Refer to NSW Health (2000) for further detail. Assessment of Alcohol Intoxication www.health.nsw.gov.au obtain alcohol and other drug use history (especially recency of use) Clinical signs of alcohol-related overdose observe vital signs may include: physical examination decreased consciousness, coma or stupor mental health examination to establish: changing mental status " level of consciousness cold and clammy skin, lowered body " orientation temperature " memory

44 Chapter 3 Alcohol Pharmacotherapies PLUS supportive therapy supportive PLUS Pharmacotherapies Withdrawal management (detoxification) management Withdrawal dvise patient re. need for further need re. dvise patient eedback results eedback concerns isten to patient’s

Specialist help or primary care and community- and care primary or Specialist help based support up Monitor and follow • Alcohol Dependent (> 20) Alcohol Dependent F L A to specialist assessment/referral Goals of treatment Likely dependent of abstinence relevance importance/ Discuss information Provide goals Establish treatment implemented Strategies discussed and Consider: • Pharmacotherapies PLUS supportive therapy supportive PLUS Pharmacotherapies Withdrawal management (detoxification) management Withdrawal dvise patient about consequences of continued of consequences about patient dvise eedback results eedback concerns isten to patient’s

Weigh pros and cons of treatment. Negotiate goals. Negotiate of treatment. cons pros and Weigh therapies supportive Encourage to AOD workerMonitor and follow up or refer necessary if specialist or • Problematic (16–19) F L A ongoing monitoring counselling, drinking, brief Change of Stage to advice and tailor Assess of treatment Goals and of hazardous moderation encourage or To manage drinking of patterns harmful Manage risk diagnostic further that or indications respond, Failure to dependence suggests is required evaluation implemented Strategies discussed and Possible: • AUDIT score + history observations dvice and information and dvice A eedback results eedback concerns isten to patient’s Risky or harmful (M: 8–15; F: 7–15) (M: or harmful Risky F L Simple range risk low of awareness Creates consequences about patient Informs brief of continued drinking, monitoring ongoing counselling, of treatment Goals levels risky at drinking those Assists of consumptionEncourage reduction alcohol 2 e.g. limits recommended to week per days free discussedStrategies and implemented of ‘trigger’ understanding greater Gain situations booklet self-help Offer Offer to follow up appointment booklet of and use progress, discuss lcohol education eedback results eedback isten to patient’s Table 3–4 Using the AUDIT score with FLAGS approach for treatment interventions Source: adapted from APF (2001, p. 14), Babor et al. (2001) and O’Connor & Simmons (2002) Low risk (M: < 8; F: 7) 8; F: (M: < Low risk F L concerns Provide A and information of treatment Goals awareness General Reinforces/maintains drinking low risk patients Assists who patients problems, whose or cut down, have may circumstances change

45 lowered blood pressure, tachycardia/ ALCOHOL WITHDRAWAL bradycardia breathing difficulties, slow and noisy General Guidelines for Alcohol respirations Withdrawal Management

Managing overdose: Withdrawal management is just one aspect of managing alcohol dependence and should

Alcohol maintain airway, breathing and circulation never be considered ‘the cure’. Changing es- refer to hospital for further assessment tablished behaviours takes time; relapse is common. Well planned interventions and en- As polydrug use complicates any clinical pic- gagement in activities supporting behaviour ture, obtain drug use history where possible, change will assist long-term recovery. in particular use of other central nervous system depressants such as methadone and See Chapter 13 heroin. Psychosocial Interventions www.answd.com.au ALCOHOL DEPENDENCE Tip Sheets

Alcohol dependence is a complex syndrome, Depending on drinking history, medical risk with both physiological and psychological signs and level of social support, alcohol with- and symptoms. drawal can be effectively managed in a home or inpatient setting. To establish a withdrawal management plan: See Chapter 1 Overview and Introduction 1. Assess current consumption levels undertake AOD, medical, social history Key features of alcohol dependence include: and mental health assessment tolerance or narrowing of drinking reper- toire 2. Predict likelihood and severity a perceived ‘loss of control’ over one’s of withdrawal drinking behaviour/salience of alcohol Withdrawal is likely where: over other issues there is an alcohol-related reason for ad-

withdrawal (physical and psychological) mission/assessment symptoms on cessation of use there is regular alcohol use of > 80

relief or avoidance of withdrawal symptoms grams per day (males), > 60 grams per by drinking day (females)

rapid recommencement of pre-estab- patient > 30 years (significant alcohol with- lished, or high-risk drinking patterns after drawal is unlikely under the age of 30) a period of abstinence < 10 days after last drink (withdrawal usually commences within 6–24 hours of last drink, and may last 2–12 days) there is a history of alcohol dependence/ significant previous withdrawal history AUDIT Score > 12

46 Chapter 3

other depressant/sedative medications Ensure the patient and carer are actively inare currently used volved in developing the treatment plan and pathology results are unusual e.g. raised are aware of: serum GGT or MCV withdrawal commencement date there is presence of alcohol-related dis- possible symptoms and has discussed ease (e.g. alcohol-related liver or cardiac expectations of withdrawal process disease, pancreatitis, hepatomegaly)

medication regimes Alcohol physical appearance is suggestive of harmful alcohol use (parotid swelling, abnormal support and emergency systems skin vascularisation, conjunctival injection) there is serious intercurrent illness e.g. head See Chapter 2 injury, diabetes, epilepsy, psychosis, infec- General Principles tion, poor nutrition, head injury, significant liver disease, pancreatitis, cardiac or respi- Psychosocial and Physical ratory disorders (NSW Health, 2000) Support During Alcohol Withdrawal The severity of alcohol withdrawal can be predicted by: reorientate and provide reassurance use simple commands, brief explanations, previous withdrawal history (past history of repetition (if required), use calm but firm seizures, hallucinations, delirium) voice duration and amount of alcohol used (quan- treat symptoms e.g. headache, diarrhoea, tity > 150g per day predictive of severe generalised aches and pains, nausea and withdrawal) vomiting etc. and monitor and observe

presence of other illness or injury increases for seizures or other medical complica- severity and likelihood of complications tions

use of other psychotropic drugs may re- encourage fluids and light meals e.g. sult in additive or synergistic effects vegemite on toast (Adapted from NSW Health, 2000; Hulse et ensure calm, uncluttered and comfortable al., 2002) environment with dim lighting, comfortable clothing and clean bedclothes The progress of the alcohol withdrawal syndrome can be seen in Figure 3–3. Delirium Tremens (the ‘DTs’) Delirium tremens is a medical emergency as- Home withdrawal management sociated with untreated alcohol withdrawal, Home withdrawal may be suitable where: occurring 3–14 days after stopping drinking. It occurs in < 5% of patients (Lopatko et al., 2002) GP is able and willing to provide home and may be fatal (Ryder et al., 2001). monitoring carer support is available at home Main features of the DTs include agitation, the patient has organised responsibilities restlessness, gross tremor, disorientation, and commitments (e.g. work) fluid and electrolyte imbalance, sweating and the patient’s physical and emotional con- high fevers, visual hallucinations and para- dition is appropriate for home withdrawal noia (Lopatko et al., 2002; NSW Health, 2000).

47 Observation and ongoing assessment — Diazepam alcohol withdrawal observation charts Benzodiazepines (most commonly diazepam, Withdrawal charts provide a guide to the se- or oxazepam in the case of impaired liver verity of withdrawal symptoms and use of phar- function) are the drugs of choice in manag- macotherapy, but are not diagnostic instru- ing alcohol withdrawal, as they: ments in themselves. A chart and guidelines for clinical management incorporating the vali- alleviate many withdrawal symptoms

Alcohol dated Clinical Institute Withdrawal Assessment are effective in preventing development for Alcohol — Revised Version (CIWA–AR), of complex withdrawal features when the most commonly used instrument in Aus- given early tralia, is provided at Appendix F. have a wide margin of safety, provided supervision is adequate See Appendix F have low likelihood of cross-dependence, when established regimes for withdrawal management are used Pharmacological Management of Alcohol Withdrawal If essential prerequisites for home with- Medications (see Table 3–5) (including drawal management have been met, home benzodiazepines), combined with supportive withdrawal using benzodiazepines may be care can assist in reducing severity of with- appropriate (see Table 3–6) (See also drawal symptoms in the home and inpatient Saunders et al., 1996). environment. See Chapter 2 General Principles

Seizures Severe withdrawal

vomiting extreme agitation Mild disorientation withdrawal confusion paranoia hyperventilation anxiety delirium tremens agitation tremor Mortality: up to 40% nausea from infections, fever, tachycardia fluid loss if untreated; hypertension less than 1% with disturbed sleep adequate treatment Severity of signs and symptoms raised temperature Hallucinations 1 2 3 4 day days days days Figure 3–3 Progress of alcohol withdrawal syndrome www.health.nsw.gov.au Source: NSW Health (2000, p. 41)

48 Chapter 3

Benzodiazepines for withdrawal Withdrawal may complicate any hospital management in inpatient/hospital setting presentation. Withdrawal management An inpatient setting is more appropriate if se- should occur several weeks prior to surgery, vere withdrawal or seizures are likely, or for where possible. those who are older, polydrug users, or physi- cally or psychologically unwell. The Alcohol There is NO place for the prescription of alco- Withdrawal Observation Chart provides a di- holic beverages in the management of azepam regime for inpatient settings. Also see alcohol withdrawal. Alcohol Palmer (2001) and NSW Health (2000).

See Appendix G

Table 3–5 Medications commonly used for withdrawal management

Drug Main Indications

Thiamine 100 mg IMI/O for at least 5 days (oral dose for two weeks, or until eating well). Treats or prevents Wernicke’s, cerebellar ataxia and peripheral neuropathy, and assists cognitive recovery

Paracetamol p.r.n. for management of headache and mild muscular pain (exclude prior liver disease)

Multivitamins e.g. folic acid, Multi B forte for poor nutrition or poor initial appetite

Antiemetics e.g. metoclopramide; for control of nausea and vomiting, p.r.n. Sedative effects assist sleeping

Antipsychotics e.g. haloperidol may be indicated in small doses (2–5 mg if hallucinating, or if agitation is of concern and uncontrolled by diazepam). Avoid phenothiazines as they lower seizure threshold

Antidiarrhoeal agents p.r.n. e.g. loperamide (as indicated)

Source: Lopatko et al. (2002); Palmer (2001); Wood & Pead (1995)

49 AFTER-CARE which also offer support groups for partners (Al-Anon) and children (Al-Ateen) of drinkers. Locate your local AA program in the tel- Self-help Resources ephone directory or the regional service via Self-help resources can be useful tools to as- the Internet. sist patients to reduce or cease use of alcohol. These resources work best when used in Pharmacotherapies to Reduce

Alcohol conjunction with a health check-up, follow- Relapse/Promote Abstinence up or counselling session. Controlled trials have shown that some medications effectively reduce relapse amongst de- See p. 54, Resources pendent drinkers. These medications are best used as part of a comprehensive psychosocial treatment plan, such as counselling, motiva- Self-help Groups tional interviewing, relapse prevention, goal setting, risk and cue identification (APF, 2001). Alcoholics Anonymous, or AA, is a worldwide The most common medications used for pro- mutual help organisation with over 2 million moting abstinence are described in Table 3–7. members. It accepts no outside contributions and is run by and for ‘recovering alcoholics’. The recovery program is based on universal spiritual principles. AA is a fellowship of sup- ALCOHOL-RELATED port that encourages altruistic behaviour but BRAIN INJURY (ARBI) makes no demands of its members apart from a desire to remain sober. The longevity of sobriety and positive attitude of many mem- Prolonged high risk use of alcohol may result bers can be exemplars for many patients. AA in specific psychological and biochemical meets in most towns in Australia, many of changes that may be described as alcohol-

Table 3–6 Diazepam regime for home/outpatient withdrawal

8 a.m. 12 midday 5 p.m. 10 p.m.

Day 1 10 mg 10 mg 10 mg 10 mg

Day 2 10 mg 5 mg 10 mg 10 mg

Day 3 10 mg 5 mg 5 mg 10 mg

Day 4 5 mg 5 mg 5 mg 5 mg

Day 5 5 mg – 5 mg 5 mg

Day 6 5 mg – – 5 mg

Day 7 –––5 mg

Day 8 ––––

Source: Palmer (2001, p. 12)

50 Chapter 3

related brain injury (ARBI). This condition is Wernicke–Korsakoff’s often confused with dementia, or pre-morbid Syndrome deficits associated with learning disorders, This ‘syndrome’ is the result of thiamine defi- and manifests in various ways, including: ciency, essential for effective CNS function. disturbance in executive functions The acute phase, Wernicke’s encephalopathy, " is a life-threatening condition, manifesting in: poor attention, planning, organising, Alcohol problem solving abilities, have diffi- global confusional state culty in new environments or with new ocular disturbances: horizontal nystag- routines mus, ophthalmoplegia or 6th nerve palsy, " ‘concrete’ thinking, difficulties with resulting in diplopia self-awareness and insight, appear ataxia: wide-based and reeling steps, al- poorly motivated though may be obscured by polyneuropa- " rigid repetitive behaviour patterns and thies inability to recognise consequences of behaviour One symptom is required for a diagnosis " problems responding to changes in (DASC, 2000). When severe, main features routine include difficulty walking unaided, disinter- est and lassitude. Following administration memory disturbances of parenteral thiamine, rapid recovery is pos- " poor short-term memory, may confuse sible. dates/events " problems learning new information Korsakoff’s psychosis (the chronic form of the syndrome) manifests in short-term memory non-verbal disturbance loss, confusion, confabulation, and Wer- nicke’s-type symptoms. Total recovery is rare, " problems with hand-eye coordination 25% of cases are irreversible and constant and perception related tasks supervision and care may be required (Luckman & Sorenson, 1982). With abstinence, proper nutrition, and psychological intervention, significant improvement is possible. Physical examination, CT scan, and blood tests (LFT, MCV etc.) will assist diagnosis.

51 Table 3–7 Pharmacotherapies indicated for alcohol dependence

Acamprosate Demonstrated efficacy in increasing abstinence, reducing relapse, [Campral®] and reducing amount and frequency of drinking

Alcohol What it does Does not prevent withdrawal symptoms but effective in dealing with post-withdrawal cravings. Restores activity levels of GABA (inhibitory transmitter) and glutamate (excitatory transmitter) to normal. Does not interact with alcohol, is not known to have dependence inducing potential, and cessation does not produce withdrawal syndrome. Available on PBS (Authority required) Commence Post-withdrawal (2–7 days after the last drink). Does not treat withdrawal Treatment Estimated at 12 months PLUS supportive therapy. Treatment goal is time abstinence. Side effects > 1% patients complain of nausea, diarrhoea, skin rash, which may last the first 1–2 weeks only Contra- Advanced hepatic failure, renal insufficiency (serum creatinine > 120 indications micromol / L, pregnancy, lactation (refer to prescribing information)

Disulfiram Trials demonstrate modest and inconsistent efficacy in promoting [Antabuse®] abstinence What it does Produces an aversive response to the ingestion of alcohol. Inhibits production of acetaldehyde dehydrogenase, so when alcohol is consumed acetaldehyde accumulates resulting in an unpleasant flushing reaction, nausea and dizziness, vomiting, chest pain, palpitations. Large doses of alcohol may produce hypotension, arrhythmia, seizures, death Commence > 24 hours after last drink. Does not treat withdrawal Treatment Long-term. Most effective under daily supervision time Side effects Drowsiness, psychosis, peripheral neuropathy, hepatotoxicity, metallic taste, headache, visual disturbance Contra- Severe hepatic impairment, severe renal impairment, severe indications myocardial disease, hypersensitivity, thiuram derivatives, pregnancy Precautions Diabetes, hypothyroidism, epilepsy, impaired hepatic +/-renal function, cardiovascular system disease, asthma, contact eczema, contact dermatitis, lactation, prolonged used. Plan relapse (at least 7 days) to prevent adverse reactions (refer to prescribing information)

52 Chapter 3

Table 3–7 (continued) Pharmacotherapies indicated for alcohol dependence

Naltrexone Demonstrated efficacy in increasing abstinence, reducing relapse, [Revia®] and reducing amount and frequency of drinking

What it does Anti-craving agent, competitive opioid antagonist. Blocks euphoric Alcohol effects of alcohol. Non-aversive i.e. does not interact with alcohol. Not known to have dependence inducing potential. Available on PBS (Authority required) Commence Post withdrawal, usually 3–4 days alcohol free. Does not treat withdrawal Treatment Controlled trials suggest 3 months (in practice may need to consider time extending). Patients should carry a warning card in case of need for opiate analgesia. Side effects About 1% patients complain of nausea, headache, dizziness, fatigue, nervousness, vomiting, insomnia, depression, anxiety lasting first 2–3 weeks Contra- Opioid dependency (will precipitate withdrawal) or concurrent opioid indications use, acute hepatitis, hepatic failure Precautions Pregnancy, lactation, hepatic or renal impairment. Opioid analgesics will not work (refer to prescribing information)

Source: adapted from APF (2001); Palmer (2001)

53 RESOURCES

Drinking Guidelines NHMRC (National Health and Medical Research Council) 2001, Australian Alcohol Guide- lines: The Costs and Benefits of Alcohol Consumption, Commonwealth of Australia, Canberra. Alcohol www.nhmrc.gov.au

AUDIT Dawe, S., Loxton, N.J., Hides, L., Kavanagh, D.J. & Mattick, R.P. 2002, Review of diagnostic screening instruments for alcohol and other drug use and other psychiatric disorders, 2nd edn., Commonwealth Department of Health and Ageing, Canberra.

Babor, T. & Higgins-Biddle, J.C. 2001, Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care, WHO, Department of Mental Health and Substance Dependence, Connecticut, USA.

Indigenous and Public Health Media Unit 1999, National Recommendations for the Clinical Management of Alcohol-related Problems in Indigenous Primary Care Settings, Depart- ment of Health and Aged Care, Canberra, www.health.gov.au/oatsih/pubs/pdf/rec.pdf

www.dasc.sa.gov.au (pamphlets & posters)

Standard Drink Measures ATODS (Alcohol Tobacco and Other Drugs Services) 1997, The Standard Drink Guide, ATODS, QLD, www.health.qld.gov.au/atods/resources/STDDRINK.pdf

Self-help Resources Obtain resources from your state ADIS, such as: DASC 1995, The drinker’s guide to cutting down or cutting out, Drug and Alcohol Services Council, Adelaide.

DASC 2001, The Women’s Drinking Guide, Drug and Alcohol Services Council, Adelaide.

NCETA/DASC 2000, Partners of drinkers: A resource book, Drug and Alcohol Services Council, Adelaide.

54 Chapter 3

Turning Point 1996, Getting through Alcohol Withdrawal, Turning Point Alcohol and Drug Centre Inc., Fitzroy, Victoria.

IEMDGP 1996, Simple strategies to help your patients balance the use of alcohol in their lives, Inner East Melbourne Department of General Practice, Melbourne.

Other Resources and Websites DASC 2000, Alcohol Related Brain Injury, available at the DASC website or ADIS. Alcohol

www.dasc.sa.gov.au

MIMS Website:

www.mims.hcn.net.au

CDHA 2001, Public Health for Educating Clinicians: Alcohol and Other Drugs, Module.

www.cme.net.au/phec

Alliance of NSW Divisions of General Practice.

www.answd.com.au

Shand, F., Gates, J., Fawcett, J. & Mattick, R. 2003, ‘The Treatment of Alcohol Problems: A Review of the Evidence’, National Drug and Alcohol Research Centre, Department of Health and Ageing, Canberra.

www.health.gov.au/pubhlth/ publicat/document/ alcproblems.pdf

55 REFERENCES

AIHW (Australian Institute of Health & Welfare) 2002, 2001 National Drug Strategy Household Survey: First Results, Drug Statistics Series No. 9, AIHW cat. no. PHE 35, AIHW, Canberra.

Alliance of NSW Divisions 2000, GP Liaison Project Alcohol and Other Drugs Tip Sheet Series, Central Coast Health Service Drug and Alcohol General Practitioner Project, 1994–2000, Alcohol www.answd.com.au/html/drug_alcohol_resources/tip_sheets_for_gps/ AOD%20Tip%20Sheets.doc

APF (Alcohol Pharmacotherapy Forum) 2001, Diagnosis and Management of Alcohol Misuse: A Guide for General Practice in Australia, Intramed Pty. Ltd., North Sydney.

ATODS (Alcohol Tobacco and Other Drugs Services ) 1997, The Standard Drink Guide, ATODS, QLD, www.health.qld.gov.au/atods/resources/STDDRINK.pdf.

Babor, T., Higgins-Biddle, J.C., Saunders, J. & Monteiro, M.G. 2001, The Alcohol Use Disor- ders Identification Test (AUDIT): Guidelines for Use in Primary Care (2nd edn.) WHO, Department of Mental Health and Substance Dependence, Geneva, www.stir.ac.uk/departments/humansciences/appsocsci/audit/DRUGS.

CDHA (Commonwealth Department of Health and Ageing) 2002, National Alcohol Research Agenda: A Supporting Paper to the National Alcohol Strategy, A Plan for Action 2001 to 2003–04, CDHA, Canberra.

CDHAC (Commonwealth Department of Health and Aged Care) 2001, Alcohol in Australia: Issues and Strategies. A Background Paper to the National Alcohol Strategy: A Plan for Action 2001 to 2003/2004, CDHAC, Canberra.

CDHSH (Commonwealth Department of Human Services and Health) 1994, National Drug Strategy Household Survey: Urban Aboriginal and Torres Strait Islander Peoples Supple- ment 1994, AGPS, Canberra.

Chikritzhs, T., Jonas, H., Heale, P., Dietze, P., Hanlin, K. & Stockwell, T. 1999, ‘Alcohol-caused Deaths and Hospitalisations in Australia, 1990–1997’, National Alcohol Indicators Bulletin No. 1, National Drug Research Institute, Perth, Western Australia.

Collins, D.J. & Lapsley, H.M. 2002, Counting the Cost: Estimates of the Social Costs of Drug Abuse in Australia 1998–9, Commonwealth Department of Health and Ageing, Canberra.

DASC (Drug and Alcohol Services Council) 2000, Alcohol Related Brain Injury, Drug and Alcohol Services Council, Adelaide.

56 Chapter 3

Dawe, S., Loxton, N.J., Hides, L., Kavanagh, D.J. & Mattick, R.P. 2002, Review of Diagnostic Screening Instruments for Alcohol and Other Drug Use and Other Psychiatric Disorders, 2nd edn., Commonwealth Department of Health and Ageing, Canberra.

Hulse, G.K., White, J.M. & Cape, G. 2002, Management of Alcohol and Drug Problems, Oxford University Press.

Litt, J., Ali, R. & White, J. 1993, Dealing with Alcohol Problems in General Practice, Common- Alcohol wealth Department of Health Housing Local Government and Community Services, Canberra.

Lopatko, O., McLean, S., Saunders. J., Young, R., Robinson, G. & Conigrave, K. 2002, ‘Chapter 10: Alcohol’ in Hulse, G.K., White, J.M. & Cape, G. (eds.) Management of Alcohol and Drug Problems, Oxford University Press, South Melbourne.

Luckman, J. & Sorenson, K.C. 1982, Medical–Surgical Nursing: a Psychophysiologic Approach, 2nd edn., WB Saunders Company, Philadelphia.

NHMRC (National Health and Medical Research Council) 2001, Australian Alcohol Guide- lines: Health Risks and Benefits, Commonwealth of Australia, Canberra.

NSW Health 2000, Alcohol and Other Drugs Nursing Policy for Nursing Practice in NSW: Clinical Guidelines 2000–2003, NSW Health Department, Gladesville, NSW, www.health.nsw.gov.au.

O’Connor, M. & Simmons, M. 2002, Alcohol Screening and Brief Intervention: A Training Program for Veteran Service Providers, Commonwealth Department of Veterans Affairs, Canberra.

Palmer, B. 2001, Alcohol and Drug Withdrawal: A Practical Approach. A Manual for Doc- tors to Assist in the Treatment of Patients Withdrawing from Alcohol and Other Drugs, 2nd edn., Next Step Specialist Drug and Alcohol Services, Perth, Western Australia, www.nextstep.health.wa.gov.au.

Ryder, D., Salmon, A. & Walker, N. 2001, Drug Use and Drug Related Harm : A Delicate Balance, IP Communications, Melbourne.

Saunders, J., Ward, H. & Novak, H. 1996, Guide to Home Detoxification, Drug and Alcohol Department, Central Sydney Area Health Service, Sydney.

Sayer, G.P., Britt, H., Horn, F., Bhasale, A., McGeechan, K., Charles, J., Miller, G., Hull, B. & Scahill, S. 2000, Measures of Health and Health Care Delivery in General Practice in Australia. (General Practice Series No. 3), AIHW cat. no. GEP 3, Australian Institute of Health and Welfare, Canberra.

57 Victoria Police 2001, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medical Unit, Victoria Police, Melbourne.

Wood, B. & Pead, J. 1995, Practice Guidelines for Health Professionals III Alcohol Withdrawal in the Hospital Setting, University of Melbourne, Parkville, Victoria. Alcohol

58 Chapter 4

Tobacco

OBACCO smoking causes an estimated 19,000 deaths and up to 10% of hospital admissions in those aged 35 years Tobacco and over, each year in Australia (Ridolfo & Stevenson, T2001). Lifelong smokers have a 50% chance of dying from a tobacco-related disease with half these deaths occurring prema- turely. (Doll et al., 1994).

No other single avoidable factor accounts for such a high proportion of deaths, hospital admissions or GP consultations (US De- partment of Health & Human Services, 2000).

Smoking starts young with one in seven 12–15 year olds smoking.

21% of males and 18% of females currently smoke (AIHW, 2002)

PHARMACOLOGY

Tobacco contains about 4,000 chemicals including: nicotine a number of known carcinogens (e.g. nitrosamines, toluid- ine, nickel, benzopyrene, cadmium and polonium 210) 2–6% carbon monoxide hydrogen cyanide various nitrogen oxides tar

59 Nicotine is the agent responsible for physical ADVERSE PHYSICAL AND dependence. It is a toxic alkaloid, with a half PSYCHOLOGICAL EFFECTS life of 1–2 hours, that rapidly crosses the blood brain barrier to stimulate both the dopaminergic and noradrenergic pathways in Acute System Effects the brain. central nervous system (CNS) — headache, insomnia, dreams Nicotine effects on the cardiovascular system gastrointestinal (GI) — nausea, vomiting, are mediated by sympathetic neural stimula- heartburn, diarrhoea tion together with an increase in levels of cir-

culating catecholamines. It has the apparent musculoskeletal system (MSS) — paradoxical effect of being both a stimulant myalgia, arthralgias (at low doses) and a relaxant (at high doses). Nicotine produces a range of toxic effects. Local Toxic Effects These effects are mainly associated with nicotine replacement therapy (NRT): AT-RISK GROUPS sore mouth, mouth ulcers (nicotine gum)

All individuals are at-risk from tobacco local itching, erythema, burning (nicotine Tobacco smoking but some groups are at special risk: patches) nasal irritation, sneezing, watery eyes

socially disadvantaged groups — people of (nicotine spray) non-English speaking background, Indig- enous Australians, and those with mental illness have higher prevalence of smoking Chronic System Toxicity pregnant women and unborn babies Cardiovascular disease exposed involuntarily to environmental Smoking is associated with an increased in- tobacco smoke (ETS) cidence of cardiovascular disease (CVD)

children exposed environmentally to to- including: bacco in ‘smoking’ households and subject to peer pressure to commence smoking coronary heart disease — angina, myocardial infarction, sudden death, conges- tive heart failure cerebrovascular disease — transient DETECTION AND ischaemic attacks (TIAs), stroke ASSESSMENT peripheral vascular diseases — claudica- tion, aortic aneurysm Self-report of smoking status is both reliable and valid. Some smokers are sensitive about Respiratory enquiry. A non-judgmental approach that also Smoking: signals that all patients are asked will help minimise stigma. is the primary cause of chronic obstructive airways disease through mucous hypersecretion, interference with ciliary function and alveolar destruction exacerbates existing hay fever and asthma contributes to acute and chronic rhinitis

60 Chapter 4

Cancer and malignancies Men who smoke are more likely to develop Smoking is a direct cause of: impotence and have a low sperm count.

lung cancer Degenerative disease oral cavity cancers (tongue, pharynx) Smoking accelerates the ageing process of esophageal and stomach cancer skin, delays wound healing and contributes cancer of the larynx to osteoporosis. kidney and bladder cancer pancreatic cancer Injuries and trauma leukaemia One in two household fires is related to smoking with an estimated 30 deaths per year. cancer of the liver

Ingestion of tobacco butts is toxic to infants. The incidence of cancer is related to the amount and duration of smoking. Concomi- tant heavy alcohol consumption further in- Environmental tobacco smoke (ETS) creases risk, especially with oral, pharyngeal Tobacco smoke in the environment is derived and laryngeal cancer. from two sources:

downstream smoke — exhaled by Tobacco Gastrointestinal smokers Smoking is a risk factor for both peptic ulcer sidestream smoke — arising from the disease and Crohn’s disease and exacer- burning end of the cigarette bates gastrooesophageal reflux.

The adverse effects of environmental tobacco Complications related to pregnancy exposure are similar to direct smoking for and reproduction many conditions including: Smoking contributes to placental insufficiency and is a cause of placental abruption, ischaemic heart disease premature labour, spontaneous abortion, cancer — lung and sinuses stillbirth, neonatal and sudden infant death asthma syndrome (SIDS). chronic obstructive airway disease acute respiratory disease in children Babies of mothers who smoke are more likely to: sudden infant death syndrome

be born with a cleft lip and palate Nicotine Dependence

have a lower than average birthweight and Withdrawal have a higher incidence of asthma, chronic serous otitis media, behavioural Nicotine dependence problems, SIDS Tolerance to nicotine develops rapidly with 2 in 3 smokers demonstrating nicotine depend- Women who smoke have a higher incidence ence i.e. emergence of withdrawal symptoms of amenorrhoea, early menopause and prob- when they attempt to stop smoking. lems with ovulation.

61 Nicotine dependence can be assessed by While withdrawal is relatively short lived, asking two questions: many smokers relapse in the first three days and over half relapse in the first three months.

how many cigarettes do you smoke a day? A range of effective pharmacotherapies are how long after you wake up do you have available to help smokers overcome nicotine your first cigarette? withdrawal.

Those who smoke more than 15–20 a day and See Chapter 4 have their first cigarette within 30 minutes of Pharmacotherapies, p. 66 waking are likely to be nicotine dependent and are also more likely to benefit from pharmacotherapy to help manage nicotine withdrawal. Psychological effects Most psychological complications of smok- Nicotine withdrawal effects ing are a result of withdrawal from nicotine. Withdrawal effects start within several hours of the last cigarette, peak in the first 24–72 hours and resolve in 2–4 weeks. Withdrawal SOCIAL COMPLICATIONS symptoms include:

Tobacco craving Highlighting the rising cost of cigarettes can irritability, restlessness, mood swings be an effective strategy to reduce smoking. The high cost contributes to financial hard- increased appetite and hunger ship and the poverty cycle, especially in so- sleep disturbances with resulting insom- cially disadvantaged groups. nia and fatigue

dizziness Smoking is also responsible for consider- anxiety and depression able absenteeism and loss of productivity difficulty concentrating through its contribution to both acute and chronic illnesses.

62 Chapter 4

SMOKING CESSATION effectiveness and efficiency — brief inter- STRATEGIES ventions incorporating advice, follow-up and possibly pharmacotherapies are effective and achievable. Research has shown It is useful to highlight the benefits of quitting that, with such intervention, one of every to patients who often only see the unpleasant 5–6 patients will be a long-term quitter effects e.g. nicotine withdrawal, worsening cough. Quitting is beneficial, even after many years of smoking as it contributes to both im- Barriers to Assisting Smokers proved quality of life and slows progression Practice setting of many smoking-related diseases. While motivation and confidence to quit are important, one of the major barriers to clini- The Benefits of Quitting cian effectiveness is the failure to identify most smokers in a practice or clinical setting or to The benefits of quitting smoking start im- offer advice to those interested in quitting. mediately with noticeable effects in the first 72 hours (improved sense of smell and blood flow to hands and feet). Benefits con- Patients tinue to accumulate, even in those who have Around two thirds of smokers are interested smoked for 20–30 years. Table 4–1 lists the in quitting, and half try to quit each year. De- benefits to be expected after quitting. spite the difficulty of quitting, 50% of people Tobacco who have ever smoked eventually success- A range of policy and legislative changes have fully quit smoking. The success rate of those who use some form of assistance is double contributed significantly to the decline in smok- that of those who try to quit on their own. ing prevalence. These include: increasing the price of cigarettes Smoking Cessation Guidelines regulating access Various tools can be used by health care pro-

making a number of public areas and fa- fessionals in attempting to help smokers quit: cilities smoke-free

banning the advertising of tobacco The Five ‘A’s

penetrating media campaigns depicting CREATE (see below) the damage done by each cigarette Decision Balance Worksheet

Health care providers (especially GPs) can These tools should be used in the context of also make a significant difference due to: the concepts and techniques described in opportunity — over 80% of the popula- Chapter 13 of this Handbook, such as: tion visit a doctor at least once a year and

most smokers have several visits Prochaska and DiClemente’s (1986) Model of Change credibility/expectation/acceptability —

many smokers (up to 50%) are interested the principles of a patient-centred approach in quitting and see doctors as having a techniques of motivational interviewing key and supportive role in smoking ces- and brief intervention sation feasibility — brief, clear non-judgmental See Chapter 13 advice can take less than a minute Psychosocial Interventions

63 Table 4–1 Benefits of quitting smoking

Time Benefit elapsed

20 minutes • blood pressure drops to normal • pulse rate drops to normal • temperature of hands and feet increase to normal.

8 hours • carbon monoxide level in blood returns to normal • oxygen level in blood returns to normal.

24 hours • the immediate risk of heart attack starts to fall. 48 hours • nerve endings start to regrow • ability to taste and smell enhanced.

14 days • circulation improves • Tobacco walking becomes easier • lung function increases up to 30%.

1 month • most nicotine withdrawal symptoms disappear. 3 months • lung function improves • nagging cough disappears • cilia regrow in the lungs, increasing their ability to handle mucus, clean themselves and reduce infection.

9 months • risk of pregnancy complications and foetal death reduced to level of non-smoker.

1 year • excess risk of coronary heart disease half that of a smoker. There is no safe point beyond which relapse will not occur. It continues at a much slower rate beyond one year of abstinence.

5 years • risk of lung cancer decreases by half • stroke risk same as non-smoker • risk of mouth, throat and oesophageal cancer half that of a smoker.

10 years • lung cancer death rate same as non-smoker • pre-cancerous cells replaced.

15 years • risk of coronary heart disease same as a non-smoker • if you smoked 20 day, you’ve saved $49,275 (assuming $9 per pack of 20).

Collated by GASP from various sources

64 Chapter 4

The Five ‘A’s CREATE The Five ‘A’s, developed by the US Depart- CREATE is an acronym representing a tool ment of Health and Human Services and which can assist health care professionals widely adopted is an evidence-based, rigor- to identify smoking status in all patients and ously evaluated framework for smoking ces- provide assistance to those who are inter- sation in health care settings. ested in quitting.

The Five ‘A’s stand for: See Appendix I Ask Assess CREATE arises from the evidence-based im- Advise plementation guidelines developed by the RACGP (RACGP, 1998). Assist Arrange Also downloadable from the RACGP website:

The main components of the Five ‘A’s frame- www.racgp.org.au/ work are described in Appendix H. For each folder.asp?id=301 component there are brief, moderate and in-

tensive strategies. Tobacco Decision Balance Worksheet Brief strategies should take between 1–3 minutes. If time is very limited and it is likely that Not all smokers wish to quit. The model of the smoker could be seen again soon, spend change (developed by Prochaska & the time available highlighting the value of DiClemente) is a useful framework to under- quitting; alternatively give the smoker a stand the process involved in changing health- Quitline card. related behaviour.

See Appendix H See Chapter 13 Psychosocial Interventions

65 The Decision Balance Worksheet is a simple Nicotine replacement therapies tool which assists the smoker to assess their (NRTs) readiness to change. The health professional NRTs help the smoker to minimise the effects can help the smoker to complete a decision of nicotine withdrawal. They are available with- balance, by working through the smoker’s out prescription from pharmacies. A number own thoughts, beliefs and feelings. of smokers have tried these agents; however many have had insufficient instruction and See Appendix J assistance to use them effectively. Choice of agent depends upon: If the Decision Balance Worksheet reveals concerns that the smoker has about their patient preference smoking, brief motivational intervention can pattern of any previous withdrawal symp- assist the health professional to shift the toms smoker towards quitting. Chapter 13 describes combinations of agents may be necessary the concepts and techniques of motivational if patients are experiencing breakthrough interviewing. nicotine withdrawal regular review is essential to tailor the dose See Chapter 13 and monitor progress

Tobacco Psychosocial Interventions it is important to emphasise that the While the goal is to identify all smokers and smoker should abstain completely from offer advice, Premature advice or a confron- smoking while using NRT tational approach can generate patient resistance. Tailor your approach to the smoker’s Table 4–2 lists the types of NRTs available, readiness to quit. their doses and duration, side effects and contraindications. Pharmacotherapies Bupropion (Zyban®) It is important to undertake a holistic approach Bupropion offers an alternative to NRT. Smok- to smoking cessation, so that pharmaco- ers start bupropion 7 days before the negoti- therapy is not considered as a standalone ated quit date and take it for 7 weeks. treatment. Relapse prevention incorporates a range of psychosocial strategies which may include pharmacotherapies. Absolute contraindications are: previous seizures or significant risk of sei- Pharmacotherapies to assist with smoking zures cessation include: history of bipolar disorders nicotine replacement therapy (NRT) history of eating disorders (bulimia, anorexia) other drugs such as bupropion, clonidine and nortriptyline Table 4–3 describes the doses and duration, side effects and contraindications associated Pharmacotherapies can minimise withdrawal with bupropion (Zyban®). symptoms and double the likelihood of the smoker successfully quitting. Pharmaco- Clonidine and nortriptyline, while effective, therapy should be considered for all smokers should be considered as second line agents who have evidence of nicotine dependence. as they have more troubling side effects.

66 Chapter 4

Table 4–2 Pharmacotherapy of nicotine replacement therapies

Type Dose and Duration Side Effects Contra- indications Less 10-20 cigs More than than 10 per day 20 cigs cigs per per day day Patches None Nicobate® Nicobate® Transient skin Relative: 14 mg 21 mg irritation, itching, • Ischaemic dreams, sleep heart disease Nicorette® Nicorette® disturbance, 10 mg 15 mg indigestion, diarrhoea Absolute: Gum None 2 mg, 8–12 4 mg, 8–12 Jaw discomfort, • Recent MI per day per day nausea, • Serious indigestion, arrhythmias Tobacco hiccups, excess • Unstable saliva, sore throat angina • Inhaler None Nicorette® Not recom- Mouth and throat Pregnancy 6–12 mended irritation, cough, cartridges nausea and per day indigestion

Table 4–3 Pharmacotherapy of bupropion (Zyban®)

Type Dose and Duration Side Effects Contra- indications Less 10–20 More than 10 cigs per than 20 cigs per day cigs per day day Headaches, 1. seizure dry mouth, disorders or Bupropion 150 mg for 3 days, then 150 mg impaired significant risk b.d. for 7 weeks sleep, of seizure seizures, 2. bulimia nausea, 3. anorexia constipation, nervosa, anxiety, and 4. bipolar dizziness disorders

67 Other Strategies Acupuncture, hypnosis and relaxation therapy have not been found to be effective in randomised controlled trials.

See Chapter 14 Alternative Therapies Tobacco

68 Chapter 4

RESOURCES

Quit books These useful and practical booklets should be given to all smokers who are interested in quitting.

Quitline 131 848 Quitline counsellors have extensive training in both behavioural and motivational interviewing techniques. Counselling services are available in most languages (with interpreter support) and provide the flexibility of call-back and follow-up calls.

Websites Australian Government Department of Health and Ageing National Tobacco Strategy The ‘National Tobacco Strategy 1999 to 2002-03: a framework for action’ was endorsed by the Ministerial Council on Drug Strategy (MCDS) in June 1999. It builds on the National Health

Policy on Tobacco 1991. It emphasises a national collaborative approach to tobacco control Tobacco issues, nominating a range of government, non government and community partnerships and links.

www.health.gov.au/pubhlth/ strateg/drugs/tobacco/

Quit SA An expanding list of information sheets and links to related sites. Also provides information about Quit SA programs and services, and links to publications.

www.cancersa.org.au

National Tobacco Campaign A reference to all facets of the current national campaign, ‘Every cigarette is doing you damage’ including background information. Also includes the Quit Because You Can booklet online and other help with quitting.

www.quitnow.info.au

Other Reading Bowman, J.A. & Walsh, R.A. 2003, ‘Smoking intervention within alcohol and other drug treatment services: a selective review with suggestions for practical management’, Drug and Alcohol Review, vol. 22, pp. 73–82.

69 Action on Smoking and Health (Australia) Links to newsletters, press releases, advocacy opportunities and information about litigation. Also links to Australian tobacco control legislation and a graphic depiction of what could happen to a smoker’s body.

www.ashaust.org.au

Tobacco Control Supersite Maintained by Simon Chapman, a leading Australian and international tobacco control ad- vocate. A great source of links to other Australian and international tobacco control sites.

www.health.usyd.edu.au /tobacco

Treatobacco.net A unique source of evidence-based data and practical support for the treatment of tobacco dependence. It is aimed at a wide range of professional groups including: physicians, nurses, Tobacco pharmacists, dentists, psychologists, researchers and policy makers.

www.treatobacco.net

Royal Australian College of General Practitioners (RACGP) ‘Green Book’ View or download a copy of the evidence based guidelines on implementation ‘Putting Prevention Into Practice’ (‘Green Book’).

www.racgp.org.au/reports/ greenbook/implementation.htm

Treating Tobacco Use and Dependence Public Health Service, US Department of Health & Human Services (2000). Treating To- bacco Use and Dependence.

www.surgeongeneral.gov/ tobacco/

Guidelines for Smoking Cessation National Advisory Committee on Health and Disability (1999). Guidelines for Smoking Ces- sation. (Wellington, New Zealand)

www.nzgg.org.nz

70 Chapter 4

Groups Supporting Smoking Cessation ACT South Australia Cancer Council ACT Quit SA PO Box 84 PO Box 929 Jamison Centre ACT 2614 Unley SA 5061 Ph: 02 6262 2222 Ph: 08 8291 4173 New South Wales Tasmania NSW Health — Tobacco & Health Unit Quit Tasmania Locked Mail Bag 961 2 Midwood St North Sydney NSW 2059 New Town TAS 7008 Ph: 02 9391 9620 Ph: 03 6228 2921 Northern Territory Victoria Department of Health and Community Quit Victoria Services PO Box 888 Tobacco Action Project Carlton VIC 3053 PO Box 40596 Ph: 03 9635 5522 Casuarina NT 0811 Western Australia

Ph: 08 8999 2690 Tobacco Quit WA Queensland Department of Health Queensland Health PO Box 8172 PO Box 48 Perth Business Centre Brisbane QLD 4001 Perth WA 6849 Ph: 07 3234 1709

GASP (GPs Assisting Smokers Program) A coalition of clinical groups with an interest in smoking cessation:

RACGP AMA Flinders University Adelaide University Quit SA Anti-Cancer Council Asthma Foundation National Heart Foundation, SA Divisions Inc. Rural Doctors Association DATIS

71 REFERENCES

AIHW (Australian Institute of Health and Welfare) 2002, 2001 National Drug Strategy House- hold Survey: First Results. Drug Statistics Series, AIHW Canberra.

Doll, R., Peto, R., Wheatley, K., Gray, R. & Sutherland, I. 1994, ‘Mortality in relation to smoking: 40 years’ observations on male British doctors’, BMJ, 309, 901–11.

GASP (GP Assisting Smokers Program), cited in Litt, J. 2002, ‘How to provide effective smoking cessation advice in less than a minute without offending the patient’, Australian Family Physician, vol. 31, issue 12, pp. 1087–1094

Prochaska, J.O., DiClemente, C.C. 1986, ‘Toward a comprehensive model of change’ In Miller, W.R., Heather, N. (eds) Treating Addictive Behaviors: Processes of Change, Ple- num Press, New York, 3–27.

Ridolfo B, & Stevenson, C. 2001, The Quantification of Drug Caused Morbidity and Mortality in Australia, 1998, Australian Institute of Health and Welfare, Canberra.

Tobacco U.S. Department of Health and Human Services 2000, Reducing Tobacco Use: A Report of the Surgeon General, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, Georgia, USA.

72 Chapter 5

CannabisCannabis

ANNABIS is the most commonly used illicit drug in Australia. Cannabis is the general name used for the CC products of the plant Cannabis sativa. While most people CwhoC use cannabis do not experience problems, it is the most common illicit drug dependency among adults, with approximately 300,000 Australians suffering from a current cannabis use disorder (Swift et al., 2001a).

PHARMACOLOGY Cannabis Cannabis Cannabis Cannabis sativa contains over 400 chemical substances — about Cannabis Cannabis 60 are responsible for its unique effects. The principal psychoactive ingredient is delta-9-tetrahydrocannabinol (THC). THC is largely responsible for the person feeling ‘stoned’ with changes in mood, thoughts, perceptions and motor skills when intoxicated. THC is lipophilic and rapidly taken up by fatty tissue. This results in a slow elimination of metabolites. THC content varies greatly (from 0.5–12%), depending on genetic and environmental factors and the method of preparation.

Common Names marijuana: lower potency dried flowering heads and leaves of the cannabis plant hash(ish): extracted resin. Also known as hash oil

73 Routes of Administration short-term memory loss tachycardia and supraventricular smoking is the most common method of arrhythmias ingestion — onset of effects is more rapid and predictable. Frequently smoked with tobacco in a water pipe (bong) or rolled Cannabis is not associated with fatal overdose. as a cigarette (joint) by mouth e.g. in food products or drunk Harms Associated with in a tea Chronic Use There are several probable harms associated PHYSICAL AND with regular (daily or near daily), sustained PSYCHOSOCIAL use (over several years): COMPLICATIONS cannabis dependence syndrome: characterised by a variety of cognitive, physical Acute Effects and behavioural symptoms, such as an In common with other psychoactive drugs, inability to control use, continued use de- the effects of cannabis depend on the dose, spite problems, withdrawal and tolerance individual and setting. Many of the following subtle cognitive impairment: affecting at- effects are perceived as positive by users. tention, memory, and the organisation The most common effects include: and integration of complex information. Evidence to date suggests that these im- relaxation pairments are not grossly debilitating, but their reversibility is unknown sense of wellbeing (euphoria) adverse respiratory effects: associated with

disinhibition the route of administration, such as chronic heightened visual and auditory perceptions bronchitis and mutagenic and carcinogenic increased appetite histopathological changes of the paren- altered time perception chyma and epithelial cells

Cannabis Cannabis Cannabis Cannabis Cannabis concentration: an increased likelihood of carcinoma e.g. carcinoma of the oropharynx and bronchus " general difficulty reduced sperm count " tendency to focus awareness on a

particular activity negative effects on the developing foetus. Avoiding cannabis is advisable if pregnant Negative Acute Effects or trying to get pregnant There can also be negative acute effects High Risk Groups such as: Certain groups are at a higher risk of developing adverse acute and chronic effects. anxiety and panic These include: paranoia

visual or auditory hallucinations adolescents

impaired coordination pregnant women. Continued smoking throughout pregnancy may increase the risk of having a low birthweight baby

74 Chapter 5

those with respiratory or cardiovascular Respiratory Function disease, whose conditions may be aggra-

vated by use examination of respiratory function may be useful those with a comorbid psychological dis-

order. Cannabis use is strongly associ- spirometry may be considered to provide ated with other drug use disorders and feedback to a user regarding the acute psychosis (Degenhardt et al., 2001). consequences of smoking cannabis Those with schizophrenia may be par- (alone or mixed with tobacco) ticularly susceptible to the negative ef- significant respiratory problems such as fects of cannabis. There is evidence that emphysema, chronic bronchitis or exac- use may exacerbate psychotic symp- erbation of asthma may be evident toms in those with the disorder, and long- term, heavy use may precipitate schizo- Cardiovascular phrenia in vulnerable individuals (Hall & Degenhardt, 2001). acute cardiovascular signs may also be present, either related to: " MANAGEMENT AND panic (e.g. hypertension, tachycardia); or " INTERVENTION STRATEGIES an exacerbation of angina pectoris Detection by Urine Analysis While many people with a substance use disorder do not seek assistance from a health Psychotropic effects of cannabis are maximal professional, there has been a substantial in- at 20 minutes and last for 2–4 hours; crease in the number of cannabis smokers cannabinoid levels can, however, be detected seeking professional assistance to quit, or to in urine up to 28 days after use. Urinary manage cannabis-related problems. cannabinoid levels are therefore not an appropriate measure of recent cannabis use, intoxication or impairment. There are no maintenance pharmacotherapies available for the management of cannabis withdrawal or relapse prevention. Psychosocial Interventions Cannabis Cannabis Cannabis Psychosocial interventions for cannabis use Cannabis Cannabis Assessment disorder are still in their infancy. Most interventions used for cannabis dependence have Assessment should focus on: been adapted from alcohol interventions. Psychosocial interventions are of greater

level and patterns of cannabis use and benefit than no therapy, and the general prin- dependence ciples of psychosocial interventions outlined evidence of psychiatric sequelae in Chapter 13 are recommended for applica- withdrawal symptoms tion in relation to problematic cannabis use. health complications of cannabis use Even one session of cognitive behavioural psychosocial context of use therapy can produce clinically significant reductions in the frequency and amount of cannabis use and related problems among severely dependent users (Copeland et al., 2001). Studies show that 6–9 sessions of cognitive behavioural therapy produce more fa-

75 vourable outcomes than brief motivational in- Management and Intervention terventions, especially with more severely dependent users. Health professionals can significantly improve the outcome for patients presenting with cannabis use disorders by: See Chapter 13 Psychosocial Interventions providing information on the harms associated with heavy long term cannabis use providing advice on reducing or ceasing use Tolerance, Dependence adopting brief motivational and cognitive and Withdrawal behavioural techniques to manage with- A dependence syndrome associated with drawal and craving cannabis use has been well described (Swift et al., 2001a, 2001b). While severe depend- Some people at the severe end of the dependence clearly exists, the cannabis dependence ence spectrum or with comorbid disorders may syndrome is generally less pronounced than be helped by referral to specialised addiction dependence associated with drugs such as and/or psychiatric services. opioids and alcohol. However, the evidence is conflicting and concerns are emerging that dependence on cannabis in some younger people may develop rapidly and be more severe than previously believed.

The most common symptoms of cannabis dependence are difficulties controlling use and withdrawal (Swift et al., 2001b).

The most common symptoms of cannabis withdrawal reportedly include: Cannabis Cannabis Cannabis Cannabis Cannabis anxiety, restlessness and irritability anorexia disturbed sleep and increases in vivid dreams gastrointestinal disturbances night sweats tremor

The symptoms are usually relatively mild and last a week or two. They do not require more than short-term symptomatic management.

76 Chapter 5

REFERENCES

Copeland, J., Swift, W., Roffman, R. & Stephens, R. 2001, ‘A randomised controlled trial of brief interventions for cannabis use disorder’, Journal of Substance Abuse Treatment, vol. 21, pp. 55–64.

Degenhardt, L., Hall, W. & Lynskey, M. 2001, ‘Alcohol, cannabis and tobacco use among Australians: a comparison of their associations with other drug use and use disorders, affective and anxiety disorders and psychosis’, Addiction, vol. 96, pp. 1603–1614.

Hall, W. & Degenhardt, L. 2001, ‘Cannabis use and psychosis: A review of clinical and epide- miological evidence’, Australian & New Zealand Journal of Psychiatry, vol. 31, no. 4, pp. 659–668.

Swift, W., Hall, W. & Teesson, M. 2001a, ‘Cannabis use and dependence among Australian adults: results from the National Survey of Mental Health and Wellbeing’, Addiction, vol. 96, no. 5, pp. 737–748.

Swift, W., Hall, W. & Teesson, M. 2001b, ‘Characteristics of DSM–IV and ICD–10 cannabis dependence among Australian adults: results from the National Survey of Mental Health and Wellbeing’ Drug & Alcohol Dependence, vol. 63, pp. 147–153. Cannabis Cannabis Cannabis Cannabis Cannabis

77 Cannabis Cannabis Cannabis Cannabis Cannabis

78 Chapter 6

Amphetamines

MPHETAMINES are the second most commonly used illicit drug in Australia after cannabis. There is evidence of increasing use and purity, and of serious harms as- Asociated with regular use. Health workers can expect to see increasing numbers of amphetamine users.

Although there are few specific interventions or treatment options for those experiencing problems related to their use of amphetamines, engaging individuals in harm reduction measures and responding to their specific needs can substantially reduce harms.

PHARMACOLOGY

Amphetamine is a closely related family of drugs with psychostimulant properties. This group of drugs includes: amphetamines used for recreational purposes, produced in illegal or ‘clandestine’ laboratories e.g. amphetamine sulphate/amphetamine and methamphetamine/methyl- amphetamine pharmaceutical quality amphetamines available on prescription for the treatment of obesity, narcolepsy, and Attention Deficit Hyperactivity Disorder (ADHD)/(ADD). These drugs include: " phentermine (Duramine®) Amphetamines " diethylpropion (Tenuate®)

79 Amphetamines 80 use resultsin: and preventing theirreuptake, amphetamine Through stimulating neurotransmitterrelease, amphetamines are: their reuptake. The monoaminesaffected by neurotransmitters andinhibiting of excitatory tem (SNS),increasingsynapticconcentrations sys- system (CNS)andsympatheticnervous Amphetamines activate thecentralnervous adrenalineandephedrine. naturally occurring relatedto are syntheticsubstancesstructurally Amphetamines (includingmethamphetamine) 2002), thepracticeofacidifying urineis acidified (VictoriaPolice,2001; Lattetal., rapidly eliminatediftheurine isartificially tively. Although amphetaminescanbemore are 12–36hoursand8–17respec- life ofamphetamineandmethamphetamine 60–70% excreted by thekidneys. The half- tabolised by theliver, withtheremaining Between 30–40% ofamphetaminesareme- Metabolism lungs andkidneys. Amphetamines areconcentratedinthebrain, Distribution

serotonin noradrenaline dopamine CNS effects CNS " " SNS effects SNS 2001, Lattetal.,2002) Police,creased temperature (Victoria tachycardia orreflex bradycardia, in- need for sleep formance; suppressionofappetiteand improved cognitive andphysical per- being, confidenceandphysical activity; (Victoria Police,2002) methylphenidate (Ritalin®) dexamphetamine : increased blood pressure, : euphoria; increasedwell- Churchill, 2002). from $50–100pergram ofpowder (Topp & ascorbic acid). 2000/01ranged during Prices ofbulkingremainder comprised agent(e.g. only around5–20mgofamphetamine, the purchased ingrams orounces, but contains (including alcoholicdrinks). Speedisusually or injected,andlessoftenmixed withdrinks smell orappearance. Speedisusuallysnorted throughtaste, qualityor purity to estimatedrug impossible cals usedensurethatitisvirtually Variation inproductiontechniquesandchemi- phetamine. in: Speedvaries recent years by themorepotentmetham- the powder hasbeensupersededin form referred toamphetaminesulphate, however Methamphetamine. Methamphetamine. Availability andQuality Crystal methamphetamine Crystal lucent to white crystals or lucent towhitecrystals has a ice’‘crushed appearance(largetrans- methamphetamine. inAsia,and Itoriginates ofhighpurity form meth) isthecrystalline 2001) (Topp &Churchill,2002). in ‘points’(0.1gram; $50 perpointin2000/ significant nasaldamage. Mostoftensold may cause into smallerparticles). Snorting jected (itdissolves inwater tobreakdown swallowedthough itisalsosnorted, orin- powder). methisusuallysmoked, al- Crystal ‘speed’ or ‘whiz’. The term effects. fact by toprolongthe alkalinisingtheirurine amphetamine usersdeliberately exploit this rhabdomyolysis (Wickes, 1993). Some believed toincreaseriskofrenalfailurefrom purity or pink),and colour (whitetoyellow, brown, orange powder) orcoarse texture (finetocrystallised Commonly knownas coarse cr speed (ice, crystal previously ystalline around $30–40each(Topp &Churchill,2002). 2000/01cost andduring most jurisdictions, widelyinpurity,vary tendtobeavailable in cinogenic orMDMA-like effects. These pills processtoproducehallu- the manufacturing suchasketamine mayDrugs beincludedin factured toappearsimilarecstasy tablets. ecstasy (MDMA),andaredeliberatelymanu- approximately 80%oftablets marketed as patterns ofusethatsuggest: patterns for dependence. However, therearetrendsin parties, ‘raves’) andnever meet thecriteria mines inspecificsocialsettings(e.g.dance Many peopletake smallamountsofampheta- injected (AIHW, 2002). everdrug mostrecently injected,andthedrug amphetamines aremostlikely tobethefirst who useamphetamines. Ofallillicits, little genderdifference amongst teenagers likely touseamphetamines, althoughthereis past 12months. Ingeneral,males are more 20–29 years have usedamphetaminesinthe last 12months. Oneinninepeopleaged useinthe amphetamines, with3.4%reporting years having andover) ever reported used found that8.9%ofthepopulation(aged 14 HouseholdSurvey The 2001NationalDrug PATTERNS OFUSE pills Methamphetamine methamphetamine base Free (Topp &Churchill,2002). cost between$30–50per ‘point’ (0.1gram) vitamin powder) for snorting. In2000/01,base substance(e.g., sometimes mixed withadry is associatedwithvein problems. Itisalso difficult todissolve withoutheat,andhence or injected.Duetoitsoilyconsistencyitis esses. Itcanbeswallowed, smoked, snorted results fromimperfect proc- manufacturing powder, ofayellow orbrown colourwhich paste, point,pure)isadamp, sticky, gluggy currentlymakeup Chapter 6 (base,wax, Long-term PhysicalEffects cal andpsychologicaleffects ofamphetamines. See Table 6–2 for anoverview ofacutephysi- Psychological Effects Acute Physical and similar tococaine, but longerlasting. & Churchill,2002). Physiological effects are symptoms comparedwithamphetamine(Topp anxiety, aggression,paranoia andpsychotic of methamphetaminearemorelikely toreport tive, andresponsible for greaterharm. Users phetamine. Itisconsideredtobemoreaddic- Methamphetamine ismorepotentthanam- PSYCHOLOGICAL EFFECTS PHYSICAL AND inare outlined Table 6–1. Level ofeffect accordingtoroute andrisks previous inmixingandinjecting. experience desiredeffect,the drug, doserequiredand number ofways, of depending ontheform Amphetamines canbeadministeredina Routes ofAdministration

deficiency eating disorders, anorexia ornutritional over time care andeatinghabits, likely toresolve nity, although with re-establishment of self- loweredweight loss, immu- malnutrition, to help‘comedown’afterabinge heroin), andmay useCNSdepressants alcohol, cannabis, benzodiazepines and (especially concurrently withotherdrugs heavy userswilloftenuseamphetamines (see Figure6–1) ‘run’), followedbyaperiodofabstinence in bingesoftenlastingdays(calleda heavy userstendtouseamphetamines 81

Amphetamines Amphetamines 82 Routes ofadministration,effectsandrisks Table 6–1 (shelving) Anal or ‘bombing’ Swallowing Snorting Intravenous ot fetRisks Effect Route dragon’ ‘chasing the inhalation Smoking/ capsule, wrapping). form (powder, quantityof drug, and and quality with vary Effects unpredictable, around 6hours). around lasting reduction, peak, slower on’,‘come slower (about 30 minutes to absorption Delayed longer lasting. slightly but injecting to relative intensity slower reduction in and onset Weaker hours. over4–6 next the intensity in reduction then minutes, few a administration lasting of within seconds Intense peakeffect effect. of duration onset and intense less Slightly above). before effect is oral (see experienced use tooccur Time is required for absorption lining. irrit may forms acidic Highly anorexic-like effect). anorexic-like can inhibit this an produce processto rategastricfood of (speed and emptying of presence Variable on effect depending intoxicationrisks, durationof and effects. drug/s,more possibly increasing more intense effect may result in taking control astronger orseeking thedose, or to inability effect, for waiting Impatience nose, sinus potentiallynasal ulcers, runny causing septum, epithelium nasal and Damages • Injection risks include: contracting(BBV). viruses borne blood increasingor risk hence equipment, for as sharingtaking needles such behaviour risk to lead may drug any with Intoxication • • potential ofexacerbation asthma. and throat, sore have sputum, bloody May of effect. rapidity for to injection second is route This uncommon. relatively Best route for controlling though dose, •

abscess at IV siteIV abscess at inflammation, infection, scarring, or may result in thrombosis in result may which contaminants, of introduction and dependence riskincreased tolerance developing of hallucinations, injury. accidents and arrhythmias, accident), cerebrovascular cardiovascular complications (incl. such aspsychosis, seizures, acute intoxicationrisks IVuse from itis, perforation. andseptum ate mucosal (Adapted fromGourlay,2000; Latt etal.,2002;VictoriaPolice,2002) Potential acutephysicaleffectsfromusinglowandhighdosesofamphetamines Table 6–2 behavioural neurological, CNS, Respiratory Gastrointestinal Skin Skeletal overdose, however death is rare) (Items marked with * indicate that deaths have been attributed toamphetamine Cardiovascular • • • • • • • • • • • • • • • • • • •

dizziness, mild tremor overstimulation, insomnia depth increased respiration rate and awareness increased confidence, self- speak talkative, excited with need to euphoria/dysphoria, restless, nausea and vomiting psychotic episodes) mild confusion, panic (rarely abdominal cramps constipation, diarrhoea or appetite suppression pupillary dilatation and reduction in fatigue increased energy, stamina increase libido with increasing doses, may fatigue impaired tasks concentration on simple improved performance or psychomotor activity with heightened alertness and pale sweaty skin headache hyperpyrexia teeth grinding reflexes increased deep tendon bradycardia), hypertension tachycardia (possibly brief palpitations, arrhythmias Chapter 6 o oe Highdoses Low doses • • • • • • • • • • • • • • • • • • • •

hypertension cardiovascular collapse* respiratory difficulty/failure* dry mouth nausea and vomiting abdominal cramps flushing orpallor behaviour stereotypicunpredictable or hyperpyrexia, diaphoresis hostility and aggression mood swings, including irrationalviolent or behaviour, pressured or slurred speech and perceptual disorders paranoid thinking, confusion dizziness headache, blurred vision, delusions, paranoia) psychosis (hallucinations, cerebrovascular accident* seizures coma teeth grinding gross body image distortions vas arrhythmia*, MI) (tachycardia, angina, cardiac stimulation oconstriction / 83

Amphetamines Amphetamines 84 Police, 2001) (Gourlay, 2001;Lattetal.,2002;Victoria Effects Long-term Psychological hypertension andcardiacarrhythmias) (suchas usepatterns term shorter cardiovascular symptomsconsistentwith sexual dysfunction valve infections, orstroke result inlungorcardiacemboli, accumulation)may due tolongerterm the blood stream(fromacuteinjectionor (e.g. kidneys). Contaminantspresentin blocking smallblood vessels inorgans due toblockages causedby particles vascular andorgandamagemay occur abscesses fection) or may causecallusing,scarring poorly maintainedinjectionsites(e.g.in- of neuropsychologicalfunctioning possible cerebralatrophyandimpairment al., 2002;Todd,2002). rence insusceptibleindividuals (Lattet rather increasethelikelihood of itsoccur- drugs areresponsibleforthe condition or however itremainsunclearwhetherthe cipitated bytheiruseofamphetamines, phrenia-like illnessthatappearstobepre- Some peoplemayexperienceaschizo- be relatedtoschizophrenia-likedisorders. episodes may cause, nor notnecessarily psychotic episodes, however, repeated use may increasethelikelihood offurther azepam). Reinstatementofamphetamine and di- treatment (usuallyhaloperidol pharmacological and withshort-term use tends toresolve oncessation ofdrug use. Amphetamine-inducedpsychosis that was precipitated by amphetamine chotic reactionofafew week’s duration Some peoplemay psy- experience abrief resolve uponresolutionof intoxication. tile hallucinations, whichtendtoreadily paranoia, acuteanxiety,lirium, andtac- amphetamine intoxication includede- psychological problems associated with

& Churchill,1996,p. 36). withdrawal (seeTable6–3)(Pead,Lintzeris tosymptomsof andusingthedrug acquiring and implicationsofuse, from related harms consider therange ofpotentialamphetamine- A practical way toengagepatientsmay beto subjective physical andpsychological. effectsLike otherdrugs, extend beyond the Harms Amphetamine-related 1998). and concentration(McKetin &Mattick, tive functioning,especiallywithmemory ontestsofcogni- poorer performance highly dependentindividualsshow Young, 2002). 2002;for (Lattetal., drugs) Saunders& ties orprostitutioninordertoobtainmoney use(e.g.drug involvement activi- incriminal based onlifestyle factors associatedwith disordersthatmay be current psychiatric etc.), andtake carenottooverdiagnose con- ment, financialinsecurity, homelessness or damagedrelationships,lackofemploy- tablished drug-orientedbehaviours(lossof, experienced bypeoplechanginglonges- consider thecontextofmultiplelosses cessation.standing problems post-drug Also of protractedwithdrawal orbecomelong thymia), oreatingdisordersmay befeatures depression, othermooddisorders(e.g.dys- Amphetamine-related harms Table 6–3 Other general measuresinclude: are intoxicated anduncomfortableinclude: strategiesfor managingclientswho Generic age somaticcomplaintsasthey emerge. andman- aspects (reassurance andsupport) Focus onthemanagementofpsychosocial mine andcocaineintoxication arethesame. Management strategies for acuteampheta- Uncomplicated Intoxication Acute Adverse Effects: INTERVENTION STRATEGIES MANAGEMENT AND need totalk whilst allowing theusertosatisfytheir avoidance ofconfrontationorarguments keeping thepersonsafe preventing to selfandothers harm andreassurance provision of support provision ofnon-stimulating environment Secrecy/stigma Alienation Supplying Dealing dealers by off Ripped quality drug Unknown relationships Poor Underworld Police andjail money enough Not custo diitainItxcto Intoxicated Intoxication Administration Acquisition Needle sharing Nasal infections BBV Contaminants Thrombosis and scarring Vein abscesses Chapter 6 Death problems Cardiovascular Stroke grinding Teeth Seizures Sleeplessness Restlessness Hallucinations Delusions Paranoia immunityPoor Hyperthermia Dehydration Tachycardia lossWeight Agitation

cient (Wickes, 1993) sedation frombenzodiazepines isinsuffi- be indicatedfor psychoticepisodeswhere antipsychotic agentse.g. may haloperidol, benzodiazepines required ifthepersonisdependenton symptoms settle). Higherdosesmay be orally, repeatedevery 1–2hoursuntil ronmental measures(diazepam 10–20mg symptoms andarenotcontrolledby envi- tation andanxietyarethemostprominent benzodiazepines may beindicatedifagi- agement tomaintainfluidintake provision offood andfluidswithencour- used) tainty regardingdrugs screening may beusefulifthereisuncer- drug ofvitalsigns(urine monitoring as possible reduction ofenvironmental stimuli asmuch relatives tostay withtheperson and friends encouragement ofsupportive dence thatthesituationisundercontrol creation ofasensesecurityandconfi- behaviour problems Relationship druguse Other avoidance Social sex Unsafe Accidents/injury Risk taking Parenting Driving use Alcohol fights Aggression/ crash Withdrawal/ functioning social Poor Dependence mood Flat thoughts Bizarre Job issues drug use to Lapse ideas Suicidal Cravings Restlessness Depression 85

Amphetamines Amphetamines 86 diagnosis accurate Obtain 1. tions include: psychostimulant intoxication withcomplica- sive care. Managementstrategiesfor acute they canbelife inten- threatening,requiring Complications arerare,butwhentheyoccur Complications Intoxication with Acute AdverseEffects: (with orwithoutpsychosis)(Wickes, 1993) psychostimulant inducedparanoid ideation violence may beanoutcome of rhabdomyolysis, renalfailure bowel ischaemiaandinfarction, cerebral infarctions,aorticdissection, sions, subarachnoidhaemorrhagesand brillation, asystole),hypothermia,convul- arrhythmias (ventriculartachycardiaorfi- (without pre-existingheartdisease), myocardial infarction(MI)andischaemia with psychostimulanttoxicityincludeacute life-threatening conditionsassociated lated pupils) creased blood pressure, temperature, di- psychostimulant toxicity (tachycardia, in- high arousalstatesmay mimic site, nasalseptumdamage) evidence administration(injection ofdrug phoresis, chestorabdominalpain vomiting, generalmalaise, excessive dia- initial symptomsmay include nausea, dealers, ambulance officers, policeetc.) ble) relatives, orothers(friends, onlookers, frompatient(wherepossi- obtain ahistory acutely anxious, paranoidandbelligerent’ where the ‘patient may beunconsciousor usemay notbevolunteered,of drug or include indifferential diagnosis as ahistory assessment.psychiatric Ingeneral: refer medicalor where appropriate for further strategies Treat signsandsymptomsastheyarise,but Management 2.

rapidly or above 39 ifthetemperaturehyperthermia: rises disturbances be indicatedtoassistindetectingcardiac monitor vitalsigns. may ECGmonitoring agement ofpsychoticsymptoms man- institutionfor short-term psychiatric May requirereferral andadmissiontoa phenothiazines lower seizurethreshold. for psychosisifpresent,as overchoose haloperidol phenothiazines 1996) (Pead mentalhealthhistory etal., and prior related toprevious episodesofintoxication, rence ofthesebehaviours, whether they are Where possible, identifyprevious occur- aweapon. whether thepersoniscarrying (checking doors, windows, hiding). Check aboutpersonalsafety significant concern tures may manifest inbehaviours suchas interactions withotherpeople. These fea- theirsurroundingsor or ismisinterpreting be experiencing delusions, hallucinations, who appearsoverly suspicious,appearsto aboutapatient the clinicianisconcerned conduct mentalstateassessmentwhere diazepines extreme agitation: sedatewithbenzo- disturbances andhypothermia correct andmonitorfluidelectrolyte quired (Wickes, 1993) monitored. Intensive caremay bere- agitation, befullyhydrated andclosely kinase (CK)analysis, receive sedation for should havethermia) regularcreatine seizure, prolongedagitation,orhyper- rhabdomyolysis: (post- allpatientsatrisk continues toincrease tion, withintensive careiftemperature cooling measures, sedationandhydra- O C implementrapid Using andstoppingamphetamines (Peadetal.,1996,p.30) Figure 6–1 If unconscious, generalmeasuresinclude: fections (Lattetal., 2002; Wickes, 1993) cerebral haemorrhage, infarctions orin- warranted todiagnosesubarachnoidor CT scansorlumbarpuncturemay be appropriate pected, naloxone (0.4–2.0mg)wouldbe (50 mlof50%). Ifopioidoverdose issus- onset of Wernicke’s encephalopathy tousingglucoseprevent(100 mg)prior alcohol, administerintravenous thiamine if suspiciousofsignificantingestion presentation thatmay complicate or useofotherdrugs screen urineorbloodtoconfirmdiagnosis check evidenceofinjury circulation ofairway,observation breathingand Chapter 6 ‘run’ (asinglesessionofafew days toweeks), commences withtheintoxication phase, or ofspeeduse in Figure6–1,atypicalpattern ers frequentlyadopta ‘binge’ pattern. Asseen and onlyuseoccasionally. Moreregularus- Many amphetamine usersarenotdependent experience oftheuser. little relevance orimpactonthesubjective rate, insomnia,etc.)may havecreased heart amphetamine use(e.g. teeth,in- grinding the possible effects andconsequencesof about Expressing health-relatedconcerns Related Problems Amphetamine Useand of Identification andDetection AMPHETAMINES USING ANDSTOPPING 87

Amphetamines Amphetamines 88 1994). etal., ence Questionnaire(LDQ)(Raistrick (Gossop etal.,1995)ortheLeeds Depend- Scale (SDS)for psychologicaldependence theSeverity ofDependence ICD-10 criteria, assessment ofdependenceuseDSM-IVor tend tobeassociatedwithdependence. For Prolonged orhighdoseuse, andinjectinguse, may include: Other discussiontriggers toxication, withdrawal orcrash, suchas: amphetamine usemay includefeatures ofin- cussion aboutlifestyle factors incorporating use.lems withtheirdrug Triggers toassistdis- lems, many peoplewillnotlinktheseprob- erbate health,socialormentalhealthprob- While amphetaminesmay resultin,orexac- be experienced. cur, however, ifuseisceased,withdrawal may reinstatement ofuse(another may oc- ‘run’) appetite, few cravings). For dependentusers, the ‘crash’ (feeling flat,tired,withdrawn, poor followed byashortperiodofabstinence,or age (young adults) dents andmusicians) stu- medical andhospitalityindustries, occupation (e.g. shiftworkers, transport, opioids, codeine) seekingbehaviourdrug (benzodiazepines, fected injectionsitesorlesions health problems, suchaspalpitations, in- matters rious aboutotherwisese- apparent unconcern pressed delusions, feeling generallyflatorde- mental healthproblems, suchasparanoia, performance orstudy difficulty concentrating, poorwork or moodswings otherwise unexplained irritability, agitation week of theworking overwhelming tirednessatthebeginning use drug of patterns Identify 2. approach lifestyle a Take 1. ASSESSMENT (Pead etal.,1996) factors psychosocial Identify 4. medical/ of evidence Obtain 3.

physical, socialandpsychologicalissues use other drug ofuse(past2–3weeks) recent history route(s) ofadministration are 10 ‘points’ inagram) ordollars) quantity (measuredingrams, points(there use) ofdaily are morecommonthanpatterns andduration ofuse(bingepatterns pattern to referring problem’‘your drug or ‘addiction’ focus onfeelings andbehaviours rather than elicit motivation for change encourage patienttotalkaboutproblems use stresses, androleofdrug ask aboutneeds, lifestyle, current legal issues relationships, dependents employment/finances living arrangementsandaccommodation social andfamily supports current medications existing medicalcare " " urine forurine about48hoursafteruse) sources (amphetaminesaredetectable in assess value ofadditionalinformation tolerance/severity ofdependence psychiatric illness psychiatric of problems? Has usecontinueddespiteevidence their speeduse? Has thepatientlinkedproblemswith activities should return tonormal. activities shouldreturn healthandinterestinother sleeping patterns, tients themostdifficulty. After1–3months, sleeping problems andcravings causingpa- symptoms tendtosubside, withmoodswings, thefollowingDuring weeks, mostsignsand thenextDuring week,typicalcomplaintsinclude: vided andencouraged. sure thatadequatefood and fluidsarepro- thecrash phase, advisecarerstoen- During clude: sation ofuse)commoncomplaintsmay in- thecrash phase(daysDuring 1–4postces- tracted, lastingafew monthsormore. month, however, withdrawal may bepro- dissipate over thecourseoftwoweeks toa riences. Mostwithdrawal signsandsymptoms dividuals andwithprevious withdrawal expe- as illustratedinFigure6–1,variesacrossin- The ‘typical’ of pattern ‘Using andStopping’, WITHDRAWAL tation ofsurroundings irritability, possibly paranoia ormisinterpre- increased appetite pains headaches, andgeneralised achesand mood swings difficulties andsleeping sleepingpatterns disrupted strong cravings orurgestouse cravings difficulties overwhelming desiretosleep, orsleeping depressed) emotional lability(irritable, agitated, hunger fatigue andexhaustion Chapter 6 inthefollowingpriate circumstances: management Inpatient treatmentmay, however, beappro- withdrawal Inpatient somatic complaints, for example: cial toreducingtheincidenceandseverity of alcohol orotherdrugs. careiscru- Supportive for peoplewithdrawingviding support from inpro- Psychosocial managementiscrucial of Management Withdrawal Non-pharmacological cessationoftheuseamphetamines. term isany moreeffectivedrugs inachieving long- tapered withdrawal withamphetaminesorother that eitherinpatientwithdrawal managementor with cravings. There isnoevidence tosuggest reinstatementorreduceabilitytocope trigger preferred may treatmentgoal,asotherdrugs isthe Abstinence fromallpsychoactive drugs exposure for specific therapies e.g. introducingcue previous failed outpatienttreatment absence ofsocialsupports suicidal) complications(e.g.psychiatric psychotic, ortreatment observation for close medicalcomplicationsrequiring where severe withdrawal isanticipated evidence dependence ofpolydrug 1996) etal., obtaining counselling(Lintzeris situations identifying highrisk concentrating onlyontheimmediatefuture eating properly thoughts andachespains coping withmoodswings, strange relaxation techniques tips toimprove sleep with cravings means ofcoping non-pharmacological organising supports organising asafe environment 89

Amphetamines Amphetamines 90

withdrawal —amphetamines’. refer etal. toLintzeris (1996) ‘Getting through relapse prevention. information For further and outpatient programs for additionalsupport mine withdrawal, encourage involvement in Because oftheprotracted natureofampheta- usingactivities.provide distractionsfromdrug andself-carehabits, and dietary ing patterns, self-discharge.early Encourage usualsleep- are oftenrisky, andfor many, may resultin however, days 3–5following cessationofuse until themainwithdrawal symptomssubside, Patients shouldideallyremainininpatientcare emotional lability(moodchange)andcravings. of thepatient,focusing on management of grams shouldbetailoredtothespecificneeds Where inpatienttreatmentisnecessary, pro- include: ducing theseverity ofwithdrawal symptoms (1998). Medicationsthatmay assistinre- Kamieniecki, Vincent, Allsop&Lintzeris al., 2001). For areview oftheliteraturesee as areplacementtherapy (seeShearer et withdexamphetaminetrials show promise phetamine withdrawal orrelapse, however inmanagingam- cacy ofpharmacotherapies Evidence isinconclusive regardingtheeffi- and Relapse Managing Withdrawal Pharmacotherapies for

as paracetamol) user with a recent history ofpoorself-care.) user witharecenthistory erant toamphetamines, whoisapolydrug beunusualinapersontol- not necessarily sociated withheroinwithdrawal they may as- (Whilst thesesymptomsarenormally Police,metoclopramide (Victoria 2001). diar- as such loperamide, hyoscinebutylbromide, complaints Gastrointestinal insomnia and Anxiety symptoms Somatic azepam, p.r.n.foraweekorless) andpromotesleep(e.g.ritability di- course ofbenzodiazepines may reduceir- rhoea, cramps, nausea and vomiting: and nausea cramps, rhoea, : mildanalgesics(such : low dose ashort

are important. context oftheclient’sreadinesstochange setting, relapsepreventionetc.)withinthe drawal management,skilldevelopment(goal other drugs.Engagingclients,planningwith- mine usersaresimilartothoseemployedwith The principlesforinterveningwithampheta- (Kamieniecki etal., 1998) recommended: on cocaineusers. Areview oftheevidence and muchoftheoutcomeliteratureisbased trials ofcounselling(e.g.Bakeretal.,2001) alised. There arefew randomisedcontrolled amphetamine use. These shouldbeindividu- withproblematicers canusetointervene There areanumberofstrategieshealthwork- Post-withdrawal Intervention Strategies amphetamine usersandmuchmoreextensive. relapse incocaineusersisalsorelevantfor treatment outcomeliteratureformanaging son isavailabletomonitormedications.The management, ensurethatanappropriateper- For patientsundergoinghomewithdrawal employment counsellingand recreation antecedents andconsequencesofuse, volving addressingthe family support, multi-faceted behavioural treatmentin- cue exposure therapy for heavy users) vention (particularly cognitive-behavioural therapy/relapse pre- bromocryptine, amantadine bromocryptine, Cravings and dysphoria and Cravings www.answd.com.au Psychosocial Interventions See Chapter13 Cocaine See Chapter8 : desipramine, users Advise: amphetamine current For of amphetamines, anddiscourage injecting. ofoccasionaloraluselowgerating doses risks tion. Discusshazardsofinjection,withoutexag- versus ofamphetamineadministra- otherforms with Discuss advantages anddisadvantages oforal experiment to likely people For Harm ReductionMeasures Encourage awareness of: of amounts large using people For amphetamines amphetamines on single occasions, single on amphetamines or over short periods of time of periods short over or practising safe sexual behaviours (e.g. hepatitisC) transmission ofbloodborneviruses toavoidbe sterile and localinfection risks andtheusingenvironment must phernalia equipment. Stressthatallinjectingpara- that provide new needlesand of services ing equipment,andawareness oflocations if injecting,encourageuseofnewinject- administration against injection,ortouseotherformsof against dailyuse mising potential harms, suchas mising potentialharms, techniques for moderatinguseandmini- " " " avoid highdosesinanyoneepisode than injecting use routesofadministrationother to allowforrecovery planning useearlierintheweekend Chapter 6

symptoms ofheavy use, suchas: ers (Pead et al., 1996; Lintzeris etal.,1996). ers (Peadetal.,1996; per occasion;onlyuseincompanyofoth- reliable sources;tousesmalleramounts e.g. toobtainthedrugfromsame,or strategies toreduceharmfulsideeffects, ing amphetamines) with alcohol(e.g. avoid whenus- driving and especiallywhenusedincombination tence’ thatamphetaminesmay produce, ‘the false senseofpsychomotorcompe- " " " " " " " " " increased tolerance speed preoccupation withobtainingandusing after using ter andeatingbefore,during enough sleep,drinkingplentyofwa- general healthcare,suchasgetting using speed,includingalcohol avoid usingwithotherdrugswhilst work orstudy before importantevents,or avoid usingforextendedperiods,and drawal symptoms of amphetamineortomodifywith- polydrug usetoexacerbatetheeffect istration (e.g.IVuse) transition toothermethodsofadmin- physical ormentalproblems emergence orexacerbationofsocial, problems associatedwithuse continued usedespiteevidenceof 91

Amphetamines Amphetamines 92 McKetin, R. &McKenna, S. 2000, ‘Amphetamine dependenceandwithdrawal’, Topp, L.,McKetin,R.,Hando,J.&Dillon,P.nodate, Jarvis, T.R.,Tebbutt,J.&MattickR.P.1995, Alliance ofNSWDivisionsGeneralPractice RESOURCES Jarvis, T.R., Tebbutt, J. &Mattick R.P. 1995, Counselling strategies Lintzeris, N.,Dunlop, A. & D.Thornton, 1996, and AlcoholResearchCentre, Sydney, www.ndarc.med.unsw.edu.au/ndarc.nsf Turning Point CentreInc.,Fitzroy, AlcoholandDrug Victoria. supp12.pdf Dependence. An Introductory Guide Introductory An Dependence. Alcohol Supplement Alcohol Dependence. An Introductory Guide Introductory An Dependence. www.answd.com.au , No. 12,www.health.nsw.gov.au/public-health/dpb/supplements/ , John Wiley &SonsLtd.,Chichester, England. , John Wiley &SonsLtd.,Chichester, England. Getting Through Withdrawal — Amphetamines — Withdrawal Through Getting Treatment Approaches for Alcohol and Drug and Alcohol for Approaches Treatment Treatment Approaches for Alcohol and Drug and Alcohol for Approaches Treatment A User’s Guide to Speed to Guide User’s A , NationalDrug GP Drug and Drug GP , Baker, A.,Boggs,T.&Lewin,2001,‘Randomisedcontrolledtrialofbriefcognitive– Latt, N.,White,J.,McLean,S.,Lenton,Young,R.,&Saunders,J.2002,‘Centralnervous Raistrick, D.,Raistrick, Bradshaw, J., Tober, G., Weiner, J., Allison,J. &Healey, C. 1994, ‘Development of AIHW (Australian InstituteofHealth& Welfare) 2002, REFERENCES Gourlay, D.L. 2000, ‘Chapter 6.2: Amphetamines’ inB. Brands(Ed.) Lintzeris, N.,Dunlop,A.&Thornton,D.1996, Saunders, J. & Young, R. 2002, ‘Chapter 3: Medicalandpsychosocialproblems’ inHulseG., McKetin, R. &Mattick, R.P. 1998, inillicitamphetamineusers:‘Attention andmemory Comparison Kamieniecki, G., Vincent, N., Allsop, S. &Lintzeris, N. 1998, Gossop, M.,Darke,S.,Griffiths,P.,Hando,J.,Powis,B.,Hall,W.&Strang,J.1995,‘TheSeverity Shearer, J., Wodak, A.,Mattick, R.P., Van Beek,I.,Lewis, J., Hall, W. &Dolan,K. 2001, Pead, J.,Lintzeris,N.&Churchill,A.1996, behavioural interventionsamongstregularusersofamphetamine’, system stimulants’inHulseG.,White,J.andCapeG.(Eds.)2002, opiate dependenceinthecontext ofatreatmentevaluation package’, the LeedsDependenceQuestionnaire(LDQ):Aquestionnaire tomeasurealcoholand and Health, Canberra. Services University Press, SouthMelbourne, pp.Victoria, 32–44. pp. 124–140. White J., andCapeG. (eds.) 2002, with non-drug-usingcontrols’, Health andFamily Canberra. Services, samples ofheroin,cocaineandamphetamineusers’, oftheSDSinEnglishandAustralianof DependenceScale(SDS): properties psychometric pp. 1279–1287. dependence’, ‘Pilot randomised controlledstudyofdexamphetamine substitutionfor amphetamine pp. 563–572. Turning Point CentreInc.,Fitzroy, AlcoholandDrug Victoria. tobacco and other drug problems drug other and tobacco The Trainer’s Package for Health Professionals Health for Package Trainer’s The Problems Drug and Alcohol Users Psychostimulant for Survey: First Results First Survey: Addiction , DrugStatisticsSeriesNo.9,AIHWcat.no.PHE35,AIHW,Canberra. Chapter 6 , vol. 96,pp. 1289–1296. , Monograph Series No., Monograph Series of 32,Commonwealth Department , ch. , 8, Drug & Alcohol Depend Alcohol & Drug , Centrefor AddictionandMentalHealth, Toronto, Canada. Oxford UniversityPress,SouthMelbourne,Victoria, Management of Alcohol and Drug Problems Drug and Alcohol of Management From Go to Whoa, Amphetamines and Analogues, and Amphetamines Whoa, to Go From Getting Through Withdrawal — Amphetamines — Withdrawal Through Getting , Commonwealth Department ofHuman , CommonwealthDepartment 2001 National Drug Strategy Household Strategy Drug National 2001 Addiction ence Models of Intervention and Care and Intervention of Models , vol.50,pp.181–184. , vol. 90,pp. 607–614. Management of alcohol, of Management Addiction Addiction Management of Management , vol.96, , vol. 89, , Oxford , 93

Amphetamines Amphetamines 94 Topp, L.&Churchill,A.2002, Victoria Police2002, Todd, F.2002,‘Coexistingalcoholanddrugusementalhealthdisorders’in(ed.)Hulse Wickes, W.1993, University Press,SouthMelbourne,:Victoria,pp.359–373. G., White,J.&CapeG.2002, with Alcohol and Drug Problems Drug and Alcohol with of Users of , AGPS,Canberra. Amphetamines and Other Psychostimulants: A Guide to the Management the to Guide A Psychostimulants: Other and Amphetamines Custodial Drug Guide: Medical Management of People in Custody in People of Management Medical Guide: Drug Custodial Drug Trends Bulletin Trends Drug Management of Alcohol and Drug Problems Drug and Alcohol of Management , 2 nd edn.,CustodialMedicalUnit,Mornington,Victoria. , June2002,NDARC,Sydney. , ch.20,Oxford Chapter 7

Chapter 15 Ecstasy Ecstasy

CSTASY is the street name generally applied to 3,4-methylenedioxymethamphetamine or MDMA. However, E other drugs are sold as ecstasy, and ecstasy tablets often contain a range of drugs (including amphetamine, various amphetamine derivatives, caffeine, aspirin, paracetamol, or ketamine) in addition to, or in place of MDMA (Wolff et al., 1995).

Ecstasy is usually sold as a tablet or capsule. The tablets are typically identified by a symbol impressed on the surface. This leads users to refer to them as ‘white doves’, ‘love hearts’, etc. Other common street names are ‘E’, ‘Eccy’, ‘Adam’ and ‘XTC’.

PHARMACOLOGY

MDMA initially enhances the extracellular brain concentrations of serotonin but eventually serotonin becomes depleted. MDMA also induces a rapid and substantial elevation of dopamine. Serotonin has a role in regulation of aggression, mood, sexual activity, sleep, sensitivity to pain, memory and body temperature (Schloss & Williams, 1998). Dopamine plays a role in the control of movement, cognition, motivation and reward (Rawson, 1999). It is probably the mechanism underlying the stimulant properties of MDMA (Daws et al., 2000).

95 Ecstasy 96 of ecstasyuse. significant factor ininitiationandcontinuation dance music. isa Useofecstasy by friends ofyouth culturecentredon usually aspart (McKetin setting etal.,1999; Topp etal.,1997b) Ecstasy isalmostexclusively taken inasocial of increasingprevalence ofuse. months (AIHW, 2002). The currenttrendisone usingecstasyintheprevious 12 ported of peopleaged14andover, while2.9%re- by 6.1% was reported other designerdrugs Household Survey, lifetime useofecstasyor StrategyIn the2001Australian NationalDrug PATTERNS OFUSE thisasapossibility.support &Hill,1998) Coore, (Henry 1996)andritonavir nation withfluoxetine (Binghametal.,1998; adverse reactionsinvolving ecstasyincombi- or throughanadditive effect. casesof Reported by eliminationofMDMAfromthebody, altering Drug interactionsmayinfluenceMDMAtoxicity et al.,1998;Schwab1999). at greaterriskofMDMAtoxicity(O’Donohoe to reducedmetabolism,theseindividualsare been suggested(butnotvalidated)that,due enzymes involved(Tuckeretal.,1994).Ithas ple havelowactivityofCYP2D6,onethe MDMA ismetabolisedintheliver.Somepeo- totoxicitycontribute (Masetal.,1999). MDMA arethemselves bioactive andmay also to toxicity. Someofthemetabolicproducts ate increasesineffect, possibly contributing increases indosemay producedisproportion- be linear(dela Torre etal.,2000),andsmall and blood concentrationrelationshipmay not administration andlastabout4hours. Dose become apparentabout20minutesafter gastrointestinal tract (Masetal.,1999). Effects MDMA iswellabsorbedfromthe hyperthermia ispredictive ofmortality.hyperthermia become life threatening The degree of stasy useishyperthermia. Itcanquickly The mostsignificantadverse effect ofec- Hyperthermia cal effects ofecstasy. Table physi- andlong-term 7–1liststheshort- health consequencesofecstasysignificant. tial morbidityinyoung peoplethatmake the andsubstan- events ofmortality andtherisk the unpredictable natureofthoseadverse events fromecstasyuseislow. arising Itis The incidenceofseriousacuteadverse Physical EffectsofEcstasy paranoia, anxietyanddepression. commonly) negative psychological effects of and afeeling ofclosenesstoothers, and(less logical effectsincreasedenergy, ofeuphoria, MDMA producesimmediatepositive psycho- COMPLICATIONS PSYCHOSOCIAL PHYSICAL AND Topp etal.,1997a). pendence isanareaofdebate(Jansen, 1999; Whether suchproblematic useconstitutesde- progress toproblematic use(Topp etal.,1997b). able toregulatetheiruseofecstasybut some 2000; Topp etal.,1997b). Mostusersappear a trendofincreasinguseby injection(Humeniuk, Ecstasy ismainlytakenorally,buttheremaybe by users(Topp experienced etal.,1997b). ofgreater dosesbeingused,especially reports or twotabletsaretakenatatimebutthere usually intherange75–100mg.Normallyone The quantityofactiveingredientinonetabletis Chapter 7

It is typically accompanied by a number of Hyponatraemia (‘water intoxication’) clinical problems, including: Ecstasy use has also been associated with seizures hyponatraemia. Cases are marked by: disseminated intravascular coagulation features of confusion rhabdomyolysis reduced consciousness; and renal and liver impairment which may be in some cases, seizures or convulsions induced or exacerbated by the hyper- Ecstasy thermia (Green et al., 1995) In general symptoms resolve as sodium levels are normalised, with full recovery achieved Clinical signs and symptoms are consistent within a few days. However, fatalities have with malfunction of normal temperature con- been reported, apparently due to cerebral trol and water balance. MDMA can produce oedema associated with excess fluid. hyperthermia in quiet surroundings, but in the setting of ‘raves’ or dance parties, toxic- In most cases of hyponatraemia, copious ity appears to be enhanced. It is probably a amounts of water were consumed. This may combination of: be a response to a sensation of thirst induced by MDMA. Alternatively, behavioural the direct effects of MDMA disturbance, including stereotyped repeti- high ambient temperature tive actions such as water consumption, may sustained physical activity; and arise from MDMA ingestion (White et al., 1997). The administration of MDMA is as-

inadequate fluid replacement sociated with inappropriate release of anti- All impair temperature regulation (Green et diuretic hormone, arginine vasopressin al., 1995; Henry et al., 1992). (Henry et al., 1998). This would reduce

Table 7–1 Physical effects of ecstasy

Short-term effects Long-term effects

• pupil dilation • insomnia • increased jaw tension • depression and grinding of teeth • headaches • loss of appetite • muscle stiffness • dry mouth • tachycardia • hot and cold flushes • sweaty palms • hyperthermia • hyponatraemia or ‘water intoxication’

97 Ecstasy 98 explanation (Hall, 1997). The combination of tions, meansthatcontaminantsareanunlikely as others, severe whodidnotexperience reac- affected personstakingfromthesamesupply in thepreparation taken. However, of reports Severe reactions mightbeduetocontaminants or atleastuncommon. users affected, makingthisexplanation unlikely, MDMA to beamixoffirsttimeandexperienced any casesofsevere reactionsandthereappears MDMA metabolismhave notbeenidentifiedin orimpaired instances ofmuscle abnormality MDMA may adverse effects. underlie However, pathy orindividualvariability in metabolism of ofmetabolicmyo-suggested thatsomeform of adose–responserelationship, ithasbeen of outcome(Gowing etal.,2002). Intheabsence relationship The doseofMDMAisnotpredictive ofseverity Dose–response fromthewayprimarily itisused. acute adverse effects ofMDMAarise settings, thesedataalsosuggestthatthe MDMA isusedinnightclubordanceparty or water balancegenerallyoccurwhen anddisturbancesofsalt that hyperthermia alone canproduceadverse effects. Given detected,demonstrate thatMDMA drug water balancewhereMDMAwas theonly ordisturbancesofsalt hyperthermia MDMA. However, ofcases thereporting inadditionto presence ofarangedrugs acute adverse effects commonlyindicatethe incasesof screeningundertaken Drug but: hyperthermia, This adviceisstillsoundfor prevention of water.dance breaksinacoolroomanddrink dance clubowners encouraged userstotake First reportsofhyponatraemiaoccurredafter excrete excessfluid. urine formationandthebody’scapacityto the body sidered theamountable to behandledby an upperlimitof500mlperhouriscon- damage after recoveryareatriskofrecurrenceliver It appearsthatthosewhoresumeecstasyuse plantation, withsomecasesbeingfatal. progressed tofullliver failure trans- requiring neously over weekstomonths, but aminority 1999). casesresolved sponta- Mostreported episodes ofecstasyuse(Jones&Simpson, occur days orweeks aftersingleormultiple canalso apparently unrelatedtohyperthermia, However,with hyperthermia. liver damage, ingestion ofecstasy, typicallyinconjunction Severe after liver damagecanoccurshortly damage Liver of ecstasyhaving aneurotoxic effect. These studiesconstitutemountingevidence Rodgers 2000; Wareing etal.,2000). Mayfrank etal.,2000; Parrott etal.,2000; functioninecstasyusers(Gouzoulis- memory inshort-term consistently found impairment users comparedtonon-usingcontrolshave chological testsincurrentandformer ecstasy Kish etal.,2000;Reneman2000).Psy- even withmoderateuse(Gammaetal.,2000; inex-users ofecstasy,ties inbrain morphology techniques have found persistingabnormali- brain (McCannetal.,2000). Brainimaging produces damagetoserotoninaxonsinthe Animal studiesshow administration ofMDMA Neurotoxicity Simpson, 1999). of liverfailure(Andreuetal.,1998;Jones& remains aminorcontributortotheincidence and, relativetoothercauses,ecstasyuse ecstasy-related liverdamageisuncertain (Andreu etal.,1998).Themechanismof likely determinesoutcome. dose, settingandindividualbehaviourmost

anddevelopmentofchronichepatitis Chapter 7

Psychological Effects Many cases of ecstasy-induced liver damage and Complications will resolve without intervention, and simply require monitoring. However, patients devel- Depression, or low mood, and concentration oping jaundice, or with evidence of hepatic and/or memory problems are commonly re- failure, require specialist care. ported in the week following ecstasy use (Curran, 2000). Cases of persistent depression, It is also important to educate users about the panic disorders, ‘flashbacks’ and delusions importance of controlling body temperature and Ecstasy have been related to ecstasy use (Benazzi & fluid intake, early signs of adverse effects, and Mazzoli, 1991; Cohen & Cocores, 1997). the need to seek medical assistance promptly. The risk of psychiatric sequelae is probably greater when: Treatment for Ecstasy Use other drugs, particularly cannabis, are Those who use ecstasy more frequently used in addition to ecstasy (monthly to weekly) and/or use larger ecstasy is used repeatedly and at high amounts, and those who use by injection are doses over a period of months likely to be at increased risk of harm and there is a family or personal history of psy- hence constitute targets for intervention. chiatric disorders (Schifano et al., 1998) Pharmacological interventions There is currently very little information on MANAGEMENT AND pharmacological interventions for ecstasy users. Selective serotonin reuptake inhibitors INTERVENTION STRATEGIES (SSRIs), if taken concurrently with MDMA, have been shown to block usual subjective Strategies for effects of MDMA (Stein & Rink, 1999). How- Different Levels of Use ever, administration of SSRIs (e.g. fluoxetine, citalopram) subsequent to MDMA may Acute adverse effects potentiate the effects of released serotonin, Reassurance, observation and monitoring for worsening any adverse effects (Green et al., several hours in a subdued environment until 1995) and limiting their value as a treatment symptoms subside, is appropriate in most ec- agent. stasy intoxication cases (Williams et al., 1998). Non-pharmacological interventions Hyperthermia and hyponatraemia are the most significant complications necessitating See Chapter 13 intervention. In both conditions the treatment Psychosocial Interventions response needs to be rapid and intense to avert significant morbidity and mortality. In Non-pharmacological interventions (also see the case of hyperthermia, the patient may Chapter 13) which have demonstrated most deteriorate rapidly towards multiple organ failure, requiring intensive support of car- efficacy in treating psychostimulant users are: diovascular, respiratory and renal systems relapse prevention (Hall, 1997). This requires admission to an cue exposure/response prevention intensive care unit. multifaceted behavioural therapy

99 Ecstasy 100 possible ecstasyuseisidentified. when 1999), administeredopportunistically (Barry, intervention andbrief isearly purposes is apriority.Anapproachwellsuitedtothese ing priortodevelopmentofproblematicuse Attracting usersintotreatmentandinterven- also beofvalue. Contingency managementapproachesmay Chapter 7

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101 Ecstasy 102 Jones, A.L. &Simpson,K.J. 1999, ‘Review mechanismsandmanagementofhepa- article: Jansen, K.L. 1999, ‘Ecstasy (MDMA)dependence’, McCann, U.D.,Eligulashvili,V.&Ricaurte,G.A. 2000,‘(+/-)3,4-Methylene- Mas, M.,Farre,delaTorre,R.etal.1999,‘Cardiovascular andneuroendocrineeffects Henry, J.A. &Hill,I.R. 1998, ‘Fatal and MDMA’, interactionbetween ritonavir Green, A.R.,Cross,A.J.&Goodwin,G.M.1995,‘Reviewofthepharmacologyandclinical O’Donohoe, A.,O’Flynn,K.,Shields, K.,Hawi, Z. &Gill,M. 1998, ‘MDMA toxicity: noevidence for Gowing, L.R.,Henry-Edwards,S.M.,Irvine,R.J.&Ali,R.L.2002,‘Thehealtheffectsof Henry, J.A., Jeffreys, K.J. &Dawling, S. 1992, ‘Toxicity anddeathsfrom3,4- Humeniuk, R. 2000, Henry, J.A.,Fallon,J.K.,Kicman,A.T.,Hutt,A.J.,Cowan,D.A.&Forsling,M.1998,‘Low-dose McKetin, R.,Darke,S.,Hayes,A.&Rumbold,G.1999, Kish, S.J.,Furukawa,Y.,Ang,L.,Vorce,S.P.&Kalasinsky,K.S.2000,‘Striatalserotoninis Hall, A.P.1997,‘“Ecstasy”andtheanaesthetist’, totoxicity inecstasy(MDMA)andamphetamineintoxications’, no. 2,pp. 121–124. Centre, Sydney. dioxymethamphetamine (‘Ecstasy’)-inducedserotoninneurotoxicity: clinicalstudies’, 296. a majorinfluenceofmetabolicgenotype atCYP2D6’, and pharmacokinetics of3,4-methylenedioxymethamphetamineand pharmacokinetics inhumans’, Sydney. Neuropsychobiology pharmacology of3,4-methylenedioxymethamphetaminepharmacology (MDMAor ‘Ecstasy”)’, “ecstasy”: aliteraturereview’, methylenedioxymethamphetamine (‘ecstasy’)’, no. 9142,pp. 1751–1752. MDMA (“ecstasy”)inducesvasopressin secretion’, 6, pp.697–698. depleted inbrainofahumanMDMA(Ecstasy)user’, porting System porting Therapeutics, o pharmacology, Pharmacology & Experimental Therapeutics Experimental & Pharmacology Drug Use and Trends in Three Australian States: Findings from the Illicit Drug Reporting Drug Illicit the from Findings States: Australian Three in Trends and Use Drug System (IDRS System ), NDARCMonographNo.41,NationalDrugandAlcoholResearch Centre, vol. 119,pp. 247–260. , NDARC Technical No. Report andAlcoholResearch 88,NationalDrug South Australian Drug Trends 1999. Findings from the Illicit Drug Re- Drug Illicit the from Findings 1999. Trends Drug Australian South vol.13,no.2,pp.129–133. , vol.42,no.1,pp.11–16. Drug & Alcohol Review Alcohol & Drug , vol. 290,no. 1,pp. 136–145. British Journal of Anaesthesia of Journal British Lancet Drug & Alcohol Dependence Alcohol & Drug Lancet Addiction Biology, Addiction Drug Trends 1998. A Comparison of Comparison A 1998. Trends Drug Neurology , vol. 340,pp. 384–387. , vol.21,no.1,pp.53–63. , vol. 351,no. 9118,p. 1784. , vol.55,no.2,pp.294– Alimentary Pharmacol- Alimentary vol.3,pp.309–314. Lancet, , vol.79,no. Journal of Journal ,vol. 53, vol,352, Psycho- Chapter 7

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103 Ecstasy 104 Chapter 8

Chapter 15 Cocaine

OCAINE is a stimulant derived from the South American Cocaine coca plant. It is imported in the form of a salt, cocaine C hydrochloride, a white odourless crystalline powder with a bitter taste. Cocaine base can be extracted from the powder to form rocks or crystals known as ‘freebase’ or ‘crack’ that are smoked and produce strong subjective effects almost immediately.

Although it is relatively easy to make crack from cocaine hydrochloride, and some Australian cocaine users report doing this, there is little evidence of widespread or problematic crack cocaine smoking in Australia to date.

PHARMACOLOGY

Cocaine blocks the reuptake of dopamine (DA), noradrenaline and serotonin at presynaptic locations, thus increasing the concentration of these transmitters at postsynaptic receptor sites (Chesher, 1993). DA concentration is particularly increased, and is thought to be the basis for cocaine’s abuse potential. Cocaine also stimu- lates the sympathetic nervous system, which accounts for its acti- vating effects.

Tolerance to the acute effects develops extremely rapidly, before the depletion of plasma levels. Most of the active drug is metabolised in the liver, but some is acted on by plasma esterases, and a small amount is excreted unchanged in the urine (Schuckit, 1995). Cocaine metabolites may be detected in urine for three days or longer following use.

105 Cocaine 106 people. In1998, 8%ofAustralians aged Cocaine useismostcommon amongst young Age year (1.9%versus 0.9%)cocaineuse. lifetime (5.3%versus 3.3%)andpast to report In 1998,malesweremorelikely thanfemales Gender in 2001(AIHW, 2002). past year increasedfrom0.5%in1993to1.3% whohadusedcocaineinthe The proportion Past Year 2001 (AIHW, 2002). time increasedfrom2.5%in1993to4.4% having usedcocaineatsome who reported The proportionoftheAustralianpopulation Lifetime PATTERNS OFUSE PREVALENCE AND Less common: Most common: Australian StreetNames white lady snow blow toot nose candy okey doke charlie coke cocaine Darke etal.,2000 Darke (Darke etal.,2002b). heroin usersinSydney increasedmarkedly jection ofcocaineamongst primary former decreased substantially, thefrequencyofin- 2001, whentheavailability anduseofheroin or ‘CC’ (cocainecocktail) orsequentially. In simultaneouslythe twoina drugs ‘speedball’ mitted heroininjectors, whoadministered Sydney. It wasmostapparentamongst com- The late1990s 2002). more expensive thaninSydney (Topp etal itishardertogetand other jurisdictions 2002a). Althoughcocaineisavailable in use, especiallyinSydney etal., (Darke marked increaseincocaineavailability and Since thelate1990stherehasbeena AVAILABILITY who snortit(Kayeetal experience moreassociatedharm, thanthose higher quantityandfrequency ofuse,and Those whoinjectcocainetendtohave a (Chesher, 1993; Platt,1997). injected and60minutes whensnorted is typically 15to30minuteswhenthedrug the half-life ofcocaine’s active metabolitesis minutes. Durationofactionisrelatively brief: Peak blood levels develop withinfive to30 andwithintwominutes wheninjected. snorted of administration: withineightminutes when jected). Onsetofactionisrapidviaeitherroute orintravenouslyintranasally (snorted) (in- In Australia,cocaineisgenerallyadministered ADMINISTRATION ROUTES OF in theirlifetime,and3%thepastyear. 20–29 yearsreportedhavingusedcocaine saw an ., ., 2000). increase inuse . , fall intotwogroups: People whousecocainemoreheavily tendto amounts infrequentlyandwithfew problems. small Most Australians whousecocainesnort TYPES OFUSERS the needformorecocaine. Such rapidmoodchangesseemtostimulate absence ofeuphoriaorevenadysphoria. short durationandisfollowedbyeitheran experienced aftercocaineinjectionisofonly (Chesher, 1993).Thus,theintensepleasure its effectsattempttorestorenormalfunction) where theneuronsonwhichcocaineexerts as aresultofrapidneuroadaptation(i.e., fects ofcocainedevelopsextremelyquickly, arise becausetolerancetotherewardingef- This destructivepatternofuseappearsto til eitherthesupplyoruserisexhausted. administered atshortintervalsrepeatedlyun- caine heavily dosoin ‘binges’, i.e. whereitis A substantialproportionofthosewhouseco- BINGEING lowing use). ‘come down’ (aversive fol- recovery period tion withcocaineaswell astomedicatethe users; areusedbothinconjunc- otherdrugs Cocaine userstendtobeextensive polydrug POLYDRUG USE heroin often (but notalways) inassociationwith userswhoinjectcocaine, injecting drug thedrug; and who generally snort middle-class, well-educated professionals Chapter 8 the former. ofcocaineinjectorsthan a higherproportion It isestimatedthatthelattergroup constitutes Cocaine andAlcohol Those whoinjectcocainetendtobeeither: Injectors (Topp etal may usebenzodiazepines tocomedown GHB, aswellalcoholandcannabis, and stasy, methamphetamine, ketamine, and/or suchasec- drugs tend touseotherparty and social context suchasatdanceparties, Those whosnortcocainetendtodosoina Snorters

snorted frequently.snorted are in whichlargeamountsofthedrug group progresstoproblematiccocaineuse, sudden cardiacdeaths leads toasignificantlyelevated for risk concurrent useofcocaineandalcohol posed toabout30minutes for cocainealone) which hasahalf-life oftwohours (asop- stance, cocaethylene (Schuckit, 1995), the combinationproducesathirdactive sub- of tolerance to alcohol and cocaineattenuates thedevelopment sensitises thebody’s reactiontococaine, with repeatedadministration, alcohol use ofpolydrug a commonpattern methadone (Kaye etal alcohol, cannabis, benzodiazepines and including use awiderangeofotherdrugs ing heroinandmethamphetamine, and includ- and willusuallyinjectotherdrugs added cocainetotheirinjectionrepertoire, userswhohavecommitted injectingdrug tion toinjecting;or level oftolerance andsomake thetransi- developed nasalproblems and/orahigh whohaveformer heavy cocainesnorters . , 2000).Asmallproportionofthis . , 2001) 107

Cocaine Cocaine 108 of Low Doses Other AcuteEffects Desired Effects the Effects Factors Influencing EFFECTS OFCOCAINE increased bodytemperature increased blood pressure rate increased heart increased respiration vasoconstriction dilation pupillary local anaesthesia suppressed appetite or efficiency increaseinfunctionalactivity temporary decreased needfor sleep energy control increased confidenceandfeelings of sociability, andtalkativeness gregariousness euphoria use concurrent polydrug intensity anddurationofuse route ofadministration quantity) dose (influencedbypurityaswell form (powder versus crack) ofatoxic reactiontococaine: as part lowing signsandsymptomsmay beexpected occur afterexcessive doses. Any ofthefol- Toxic reactionsarecocaine‘overdoses’.They (‘Toxic Reactions’) Acute EffectsofHighDoses stomach pain/nausea/vomiting headache rectally) to 41°C sweating/very highbodytemperature (up myocardial ischaemiaandinfarction arrhythmias cardiac arrhythmiasincludingmalignant weak, rapid pulse muscle rigidity dizziness crawling undertheskin) tile, e.g.formication(thefeelingofbugs hallucinations, mostoftenauditoryortac- confusion/delirium pallor acute stroke blurred vision convulsions acute renalfailure pulmonary oedema chest pain/angina markedly elevatedbloodpressure respiratory failure heightened reflexes tion muscle twitches/tremors/lossofcoordina- aggression/hostility anxiety/severe agitation/panic stereotyped, repetitive behaviour ‘Treatment of Toxic Reactions’ See p.111 Intranasal usersmay suffer from: users Intranasal to RouteofAdministration Physical Problems Relating COMPLICATIONS PSYCHOSOCIAL PHYSICAL AND Effects ofChronicUse Injecting usersmay suffer from: users Injecting traces ofblood cocainewhichmay contain used tosnort ofstrawsto sharing orotherequipment ofhepatitisCtransmission due slight risk perforated nasalseptum epistaxis sinusitis nasal ulcers blood nose nose runny increased pulserate heightened reflexes loss oflibidoand/orimpotence nations psychosis —paranoiddelusions, halluci- anxiety muscle twitching loss loss ofappetiteandconcomitantweight aggression orviolence depression insomnia cations canbemorecommon thanwith andinfection compli- local inflammatory fungalorparasitic be viral,bacterial, systemic andlocalinfections whichmay Chapter 8 Intensity ofcocaineusemay incur: Social Problems Chronic Use’ above. ‘Acute Effects ofHighDoses’ and ‘Effects of common cocaine-relatedproblems. See Psychological complicationsarethemost Psychological Problems Death isrelatively rare, but is associatedwith: Cocaine-related Death cardiovascularlarly complications. regardless ofrouteadministration, particu- Other physical problems may beexperienced Other Physical Problems

interpersonal problems interpersonal elevated bodytemperature cardiac arrhythmias a stroke-like CNSvascular picture agitation delirium muscle rigidity occupational problems " " " " " " HIV tion suchashepatitisC,Band transmission ofbloodborneviralinfec- endocarditis bacterial phlebitis injection-related abscesses,cellulitis, ofcocaine anaesthetic properties heroin duetothevasoconstrictiveand job loss absenteeism impaired productivity alienation fromsocialsupportnetworks paranoia leadingtoirrationaljealousy tionships heightened discordinsignificantrela- 109

Cocaine Cocaine 110

including tolerance. symptoms ofdependence,alongwithothers developSome cocaineusersclearly such (APA, 1994) Key dependenceare: for diagnosingdrug criteria Cocaine Dependence duce oreliminateuse repeated relapsedespiteresolvingtore- more orfor longerthanintended loss ofcontrolover usemanifest by using that itcausessignificantharm despiteknowing continued useofadrug financial problems legal problems " " " " " " debt todealersand/orothersmaygrow calate rapidly cocaine isexpensiveandusecanes- designed tosupportuse may betheresultofcriminalactivity may bedirectlydrug-related pounded byjobloss financial problemsmaybecom- appear aviablefinancialoption dealing orothercriminalactivitymay consisting of: after several days ofheavy cocaineuseas DSM–IV (APA, withdrawal 1994)describes ate withdrawal, however, iswell documented. the strongmotivation toresumeuseallevi- aversive natureoftheexperience for users, and by symptomsratherthanclinicalsigns. The tentious becausethesyndromeisdominated The existence ofcocainewithdrawal iscon- Syndrome Cocaine Withdrawal caine may becausedby multiple confounders tal adverseeffectscommonly attributed toco- However, manyoftheperinatal andpostna- been associatedwith: pregnancyhas Exposure tococaineduring Foetal Effects

of thefollowing symptoms: rather thandepression)andatleasttwo mood(anhedoniaorsadness dysphoric behavioural problems retardation ofgrowth ofplacenta abruption premature delivery gestation shorter " " " " " " have (Gawin &Kleber, returned 1986) mood andtheabilitytoenjoy experiences after withdrawal iscompleteandnormal resume usemay persistindefinitely, even gest thatcocainecraving andadesireto weeks (Lago&Kosten, 1994). Some sug- symptomspersistfor upto10 dysphoric withdrawal reachesitspeakin2–4days vivid, unpleasantdreams increased appetite craving psychomotor agitationorretardation insomnia orhypersomnia fatigue in individualswhomanifest: Possible cocaineuseshouldbeconsidered reactions toxic Acute problems. psychosis andcardiovasculartemporary ated withcocaineuseareanxietyconditions, The mostcommonclinicalproblems associ- Clinical Screening INTERVENTION STRATEGIES MANAGEMENT AND rather thanbycocaineitself(Addisetal that canoccurinacocaineusingmother, 2001), suchas: acute ischaemicevents behavioural abnormalities confusion oranorganicbrainsyndrome ortactile hallucinations, especiallyauditory paranoia orsuspiciousness aggressive orviolentoutbursts emotional labilityorirritability ness plusrapidpulse) an anxiety-like attack (usuallynervous- state a restless, hyperalert rate increased heart sweating elevated temperature increased reflexes mouth dry dilated pupils poor qualitypostnatalenvironment poverty single motherhood poor prenatalcare rettes use, includingalcoholandciga- polydrug Chapter 8 . , diagnosis. or urinetoxicologicalanalysiswillconfirmthe If thecliniciansuspectscocaineuse,blood entation.are: Priorities condition ofthepatientattimepres- The treatmentchosenwilldependonthe Treatment of Toxic Reactions their usemay manifest: Chronic cocaineuserswhodonotdisclose Chronic CocaineUse

(5–10 mgIV)toprevent CNShaemorrhage tion inblood pressurewithphentalomine vigorous treatmentofasustained eleva- diazepam willalsoreduceagitation repeated asrequired of 5to20mginjectedveryslowlyand control ofseizureswithdosesIVdiazepam in extreme cases, blanket ahypothermic hydration, sedation,coldwater, icepacks or control ofelevated bodytemperature with stability andtreatmentofshock circulatory emergency caretoensureaclearairway, side effects ortosellfor profit opioids torelieve withdrawal, medicate benzodiazepines, antidepressantsor seeking ofmedicationssuchas chaotic lifestyle missed appointmentsandothersignsof intoxication) during teeth(fromtoothgrinding worn inthenasalliningormucosa abnormalities abscesses) evidence ofIVdruguse(trackmarks, social problems(asoutlinedabove) loss oflibido insomnia lethargy paranoia/hallucinations suicidal ideation depression/anxiety 111

Cocaine Cocaine 112

Management Assessment Issues tobeconsideredinclude: supportive. drawal. Managementofwithdrawal islargely fective for pharmacotherapy cocainewith- There is, asyet, nogenerallyaccepted,ef- of Management Withdrawal a short-termbasisforagitation benzodiazepines maybeprescribed on sleep andeatasmuchisneeded roundings for several days andallowed to the patientshouldbeplacedinquietsur- reasons for withdrawal illicit licitand concomitant useofotherdrugs, usehistory detailed drug history detailed psychiatric nation careful neurologicalandphysical exami- seizures (Nathanetal threshold andmayincreasetheriskof haloperidol canreducetheseizure should becloselymonitoredas diazepines areinsufficient.Suchpatients psychotic patientswhenbenzo- haloperidol mayberequiredtomanage low dosesofanantipsychoticsuchas hours. pHunder6.6 The goalisaurinary orallyevery 3–4 mg ammoniumchloride with500 through acidificationoftheurine excretion ofcocainecanbehastened the possibilityofcerebralhaemorrhage out fused orunconsciouspatientwillrule CT scansandlumbarpunctureinthecon- stimulation tobecloselymonitored and placedinaquietroomwithminimal orrelatives,erably friends by supportive pref- should bereassuredandcomforted, torecover,once thepatientsstart they . , 1998)

produced betterresults. Behavioural andpsychosocial therapieshave therapy Cognitive-behavioural for cocainedependence: There isnowidelyeffective pharmacotherapy Pharmacotherapy Cocaine Dependence Treatment of

al actions have (Barrettet beendescribed if cocaineuseiscontinued,astoxic inter- SSRIs care shouldbetaken inprescribing cocaine use major depressive episodesassociatedwith but canbeeffective inthemanagementof not effective inreducingcocaineuseitself, quire antidepressants.Antidepressantsare severe andpersistentdepressionmayre- essary porary) suicideprecautionsmaybenec- if thepatientismarkedlydespondent,(tem- et al tated cocaine-inducedconvulsions (O’Dell " " " typical skillstaughtinclude: cocaine use(Carroll,2000) ing strategiesaseffective to alternatives client masteranindividualisedsetofcop- aims toreducecocaineuseby helpingthe (George etal cocaine useinopioid-dependentclients or methadonemaintenancemayreduce disulfiram asanadjuncttobuprenorphine et al increase cocainetoxicity (McCance-Katz cular responsesandconsequentlymay creases cocaineassociatedcardiovas- between disulf however, thereisapotentialinteraction . , 1996),and,inmice, SSRIshave facili- craving developing skillsforcoping with identifying thefunctionsofcocaine use identifying high-risksituationsfor relapse . . , 2000) , 1998) ., 2000; Petrakis etal iram iram and cocainethatin- . , 2000) Enhancement of psychosocial skills psychosocial of Enhancement management Contingency drugs. proaches usedforthosedependentonother eral supportiveandcommonsenseap- cocaine usersshouldfollow thesamegen- Australia, aimedatrehabilitationof efforts tive treatments for cocainedependencein Given thelack ofgenerallyaccepted,effec- approaches General Acupuncture ing programs(Volpicellietal enhancement ofsocialskillsthroughtrain- ciated withbettertreatmentoutcomeisthe an adjuncttoconventional therapy asso- be exchanged for retailgoods including money and vouchers whichcan different typesofrewards have beenused, & Fiellin,2001) benefits ofanescalatedpayment (Sindelar the immediatereward andtakingaway the violations arepunishedbothby denying uses anescalatingreward systeminwhich search-based treatmentprograms abstinence andtreatmentretentioninre- has shown promiseinincreasingcocaine they leave treatment(Carroll,2000) ing toreducetheircocaineuseeven after effects aredurable, withclientscontinu- approaches is moreeffectivethanlessintensive comorbid mentaldisorders pendent cocaineusersandthosewith control treatmentsfor moreseverely de- has beenshowntobemoreeffectivethan on methadone(Avants etal thosemaintained ent clients, particularly may beusefulfor somecocainedepend- Chapter 8 . , 2000) . , 2000)

grams thatassessandaddress theseissues disorders (Tutton&Crayton, 1993).Pro- lar disorders,and5%withattention deficit suffer withanxietydisorders,20%bipo- that 30%ofcocainetreatmentpresentations andpsychosocialproblems.ric Itisestimated Cocaine usersoftenhave multiple psychiat- disorders Comorbid

1999). place over sixmonths(Merder& Woody, that consistsof36sessionsdesignedtotake counselling approachfor cocaine dependence NIDA hasproducedamanualfor anindividual

Clinicians should: propriate to: propriate those goals, includingreferral whenap- tailor thetreatmentwherepossibletomeet achieve long-termabstinence) quency and/orquantityofcocaineuse;to through anacutecrisis;toreducefre- tient’s treatmentgoals(e.g., tomake it ensure understandingoftheclient/pa- Cristoph etal.,1999) Cristoph sociated withbetteroutcome(Crits- psychosocial treatmentprograms areas- program aspossible, asmoreintensive provide asmultifaceted andintensive a adjusted toreflectthesechanges ment, thetreatmentprogram shouldbe change throughoutthecourseoftreat- ice delivery; asgoalsandoutcomes remember theneedfor flexibility ofserv- (Simpson etal is associatedwithbetteroutcomes ment for aslongpossible, asretention seek toengageandretaintheuserintreat- on abstinence not " " " " judgetheuserandshouldnotinsist self-help groupssuchasNA family counsellors individual counsellors treatment programs . , 1999) 113

Cocaine Cocaine 114 cocaine use, theclinicianshouldattemptto: relatedto nent despitesignificantimpairment In patientswhodonotwishtobecomeabsti- change to Readiness not (McLellanetal have betteroutcomesthanthosewhichdo through: help clientsrebuild alife withoutcocaine their own actions emphasise theclient’s responsibilityfor future problems tween cocaineuseandcurrentand/or dependence andtherelationshipbe- others abouttheusualcourseofcocaine by educatingclientsandtheirsignificant enhance motivation toward abstinence lems have notbeenadequatelytreated abstinenceifchronicmedicalprob- term clients willfinditdifficulttoachieve long- maximise physical andmentalhealth,as retain contactwiththeclient lationship establish anempathetic, respectfulre- " " " " appropriately showing themhowtousefreetime non-drug usingpeers helping themdevelopanetworkof family counselling vocational counselling . , 1997,1998). Carroll, K.M. 2000, ‘Implications ofrecentresearch for program qualityincocainedependence AIHW (AustralianInstituteofHealth&Welfare)2002, Gawin, F.H. &Kleber, H.D. 1986, diagnosisin ‘Abstinence symptomatologyandpsychiatric Addis, A.,Moretti,M.E.,Syed,F.A.,Einarson,T.R.&Koren,G.2001,‘Fetaleffectsofcocaine: REFERENCES Crits-Cristoph, P.Crits-Cristoph, 1999, ‘Psychosocial treatmentsfor cocainedependence: NationalInstitute George, T.P.,Chawarski,M.C., Pakes,J.,Carroll,K.M.,Kosten,T.R.&Schottenfeld, R.S. Darke, S., Ross, J., Hando, J., Hall, W. &Degenhardt, L. 2000, Darke, S.,Kaye,S.&Topp,L.2002b, Darke, S.,Kaye,&Topp,L.2002a, Chesher, G.B.1993,‘Pharmacologyofthesympathomimeticpsychostimulants’in Avants, S.K., Margolin,A.,Holford, T.R. &Kosten, T.R. 2000, ‘A randomized controlledtrial Barrett, J.,Meehan,O.&Fahy,T.1996,‘SSRIandsympathomimeticinteraction’. APA Association)1994, Psychiatric (American treatment’, cocaine abusers’, and AgedCare, Canberra. Illicit DrugReportingSystem’, 1996–2000: purity, oftrendsinprice, 5year monitoring availability andusefromthe An updatedmeta-analysis’, on DrugAbuseCollaborativeCocaineTreatmentStudy’, subjects: A preliminary trial’, subjects: trial’, Apreliminary 2000, versus‘Disulfurim placebofor cocainedependenceinbuprenorphine-maintained Research Centre, Sydney. of auricularacupunctureforcocainedependence’, Canberra, pp. 9–30 160, no.15,pp.2305–2312. vol. 56, Canberra. Epidemiology, Use Patterns and Associated Harm, Associated and Patterns Use Epidemiology, Journal of Journal Psychostimulant Use in Australia in Use Psychostimulant Reporting System (IDRS System Reporting Disorders Survey: First Results First Survey:

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Cocaine Cocaine 118 Other Opioids Heroin and dependence. ever, itisestimatedthat aboutoneinthreeheroinusersdevelop suchasheroindosoonanirregularbasis.psychoactive drugs How- increasing inAustralia sincethe1980s. Mostpeoplewhouseillicit opioids andillicitheroinhasbeensteadily The useofprescribed PATTERNS OFHEROIN USE as listedin Table 9–1. andotherphysical gastrointestinal,endocrine systems nervous, O water-soluble, whitecrystallinepowder: inAustralia,illegal drug andisusuallyavailable intheform ofa frommorphine.Heroin isapotentopioidderived Heroinisan Heroin OPIOID DRUGS Chapter 9

heroin islargelymetabolised by theliverbeforeexerting ing numbersofAustralianssmoke orsnortthedrug.Oral heroin isusuallyinjectedintravenously, althoughincreas- therapeutic oradverse (sideeffects). Opioidsaffect the to producearangeofeffects whichmay beconsidered PIOID drugs mainlyactontheopioidreceptorsystem 119

Opioids Opioids 120 Opioid effects Table 9–1 cal conditions,mostnotablyasananalgesic. Morphine isprescribedforarangeofmedi- Morphine

morphine isabout25%ofinjecteddoses) liver metabolism(thebioavailabilityoforal it hasvariablebutsignificantfirst-pass in regularusers significant effectslastingupto3–6hours within minutesofsmokingorinjection,with onset ofeffects. Onsetofeffects occur heroin isashortactingdrugwithrapid lism), sothatfewuserstakeheroinorally its maineffects(highfirst-passmetabo- Other Endocrine actions Effect Gastrointestinal actions Nervous system Physical system • • • • • • • • • • • • • • •

ACTH elevated anti-diuretic hormone (ADH), reduced reduced testosterone menin with reduced libido menstrual changes, reduced libido, galactorrhoea hormone (LH); raised prolactin) resulting in follicle-stimulating hormone (FSH) and leutenising changes in sex hormones in women (low biliary spasm (elevated tone of Sphincter of Oddi) constipation nausea and vomiting pupillary constriction reducedreflex cough sedation, drowsiness, respiratory depression euphoria analgesia (pain relief) itching, sweating, flushed skin (histaminic reaction) dry mouth, skin and eyes difficulty passingurine low blood pressure pendence (methadonesyruporsolution). tablets) andfor thetreatmentofopioidde- the managementofchronicpain(methadone Methadone isalongactingopioidusedin Methadone

dosing forchronicpain are available allowing onceortwiceaday slow-release oralmorphinepreparations with significanteffects for 3–6hours it hasasimilardurationofactiontoheroin, See Tables9–2&9–8 Methadone effectsandduration Table 9–2 This meansthat: tightly (highaffinity)atthemuopioidreceptors. tial opioidagonist(i.e. low activity)andbinds sublingual tablets). isapar- Buprenorphine agement ofopioiddependence(highdose (low dosesublingualtablets),andfortheman- Buprenorphine isregisteredasananalgesic Buprenorphine (Subutex®) opioids. to This cancomplicateefforts it reduces(blocks)theeffectsofother methadone doses) heroin useorwithin24hoursofeven low other opioids(e.g. within6–8hoursof by individualswhohave recentlyused fore precipitateopioidwithdrawaliftaken such asheroinormethadone.Itcanthere- more tightlytoreceptorsthanotheropioids buprenorphine bindsinpreferenceand opioid effects generallyproducestypical buprenorphine fetTiming Half-life management effectspain in Duration of analgesic 3–8 hours after dose dependence opioid substitution treatment of 30–90 minutes after oral dose of effectsDuration in Peak effects Onset of action Effect Chapter 9 starting methadone treatment. after each dose. Hence caution is required when the client will experience increasingopioids effects methadone —during thefirstoftreatmentfew days a dose change. This is important when starting 5 half lives toachieve steady-stateequilibrium after Approximately 15–30 hours. Ittakesapproximately a day for pain management 8–12 hours, and is usually taken two or three times 20–30 hours, allowing once aday dosing

methadone from equivalentamountsofmorphineor withdrawal syndromethanwithdrawal buprenorphine appearstohaveamilder " " " duration ofeffectsaredoserelated: 3 to8hoursafteradose minutes afteradose.Peakeffectsoccur onset ofeffectsapproximately30to60 ents onbuprenorphine achieve additionalopioidanalgesiaincli- ents tobedosedevery2or3days) 24–72 hours(thisallowssomecli- high doses(e.g.12mgormore): 12–24 hours medium doses(e.g.4to8mg): for analgesia):4–12hours low doses(e.g.0.2to0.8mgused See Table9–7 121

Opioids Opioids 122 Common symptomsandtimeframesofopioidwithdrawal Table 9–3 to heroinuseispreventedaslong fects ofotheropioids(e.g.heroin)andrelapse from bindingtoreceptors.Thisblockstheef- fects, andimportantlypreventsotheropioids opioid receptorsbutproducesnoef- Naltrexone isanopioidantagonist.Itbindsto Naltrexone Time since last heroin use Common symptoms Common since lastheroinuse Time 5th to 7thdays5th 2nd to 4th days than 24hours more 12 to 24 hours 6 to12 hours weeks tomonths second week • • • • • • • • • • • • • • • • • • •

headache cravings reduce mood. Improvement in general health, and tiredness, irritability, cravings ongoing problems with poor sleep, down. Appetite returns symptoms reach their peak hot and cold flushes, increased sweating poor concentration restlessness, irritability,agitation lethargy, fatigue poor sleep back pain, pain in joints, legs or arms, poor appetite, nausea, vomiting stomach cramps, diarrhoea strong urges (cravings) to use heroin loss of appetite sweating,and hot coldflushes goosebumps agitation and irritability sweating eyesrunnysneezing, andnose, yawning return of normal sleep, levels of activity and ‘physical’ discomfort subsiding. May have most physical symptoms begin tosettle in heroinandalcoholdependence. tered inAustraliaforthepreventionofrelapse on ceasingnaltrexone.Naltrexoneisregis- naltrexone istaken.Therenowithdrawal Alcohol See Chapter3 Factors impactinguponseverityofwithdrawal Table 9–4 such asheroinandmorphine. and time frames forshortactingopioids Table 9–3 showsthecharacteristicfeatures very unpleasant,butnotlife-threatening. longed opioiduse.Opioidwithdrawalis the reductionorcessationofheavy andpro- signsandsymptomsupon of characteristic A withdrawalsyndromeistheemergence WITHDRAWAL response toopioidsafterregularuse. tolerance. Toleranceresultsinareduction adaptation andresultsinthephenomenonof at alower dose. The processiscalledneuro- duce thesameeffect thatwas onceobtained sothatahigherdoseisrequiredtopro- drugs The bodyadaptstotherepeateduseofopioid TOLERANCE Setting psychiatric conditions or medical Concomitant withdrawal and expectancy Higher doses are generally associated with Prior experience of A short history ofregular use (e.g. < 6months) is Duration of regular opioid use Opioid dose atrImpact Opioid type Factor Chapter 9 undertaken impacts upon the experience. The environment in which withdrawal is symptoms. decrease the individual’s capacitywith tocope May increase the severitywithdrawal,of or withdrawal often experience greater discomfort. Individuals who are particularly anxious about syndrome. generally associated with a milderwithdrawal greater withdrawal severity. be less severe. partial agonists (e.g. buprenorphine)appears to longer (weeks to months).Withdrawal from methadone) is typically slower in onsetandlasts Withdrawal from longer acting opioids (e.g. several years later. ties, withregularuseusuallycommencing twen- using heroinintheirlateteenstoearly Most dependentheroinusersdescribefirst Dependent HeroinUse Natural Historyof The DependenceSyndrome DEPENDENT HEROINUSE

dependence has dependence ence alonesufficientfor adiagnosisof dependence, norisphysicaldrug depend- physical dependenceisnotarequisiteof harms with persistentusedespitesignificant is thelossofcontrolover theuseofadrug, the mostsalientfeature ofthesyndrome is notan ‘all ornothing’ phenomenon grades grades of severity —it 123

Opioids Opioids 124 Overdose above.scribed include: Otherharms Side effects associatedwith opioids arede- WITH HEROIN USE HARMS ASSOCIATED in Australia Heroin Use Features ofDependent treatmentsuggests: those entering remitting condition. follow-up Long-term of Heroin dependenceisachronic,relapsing–

age 25 More commoninmaleheroin usersover than ageandgendermatched controls). 1–2% perannum (10to20timesgreater causes) for heroinusersisapproximately rate(fromall the estimatedmortality heroin isa for mostpeople dependent heroinuseisdifficulttosustain subsequent year achieve andremainabstinentineach approximately 2–3%ofuserswill ment main abstinentinthefirstyearaftertreat- 10% ofheroinuserswillbecomeandre- benzodiazepines withinlastmonth larly, andapproximately onethirdused pendent heroinusersusecannabisregu- polydrug useiscommon:overhalfofde- work colleaguesandhealthworkers closing theirdrugusetofamily,friends, deter peoplefromseekingtreatmentordis- stigma associatedwithheroinusecan to $200perday in2001) adulterants, andisexpensive (costing$50 illicit heroinhasvariable concentrationand tions aday iscommon short acting acting short drug: 2to4injec-

Harms RelatedtoInjecting Needle ExchangePrograms, 2001) (National Seroprevalence StudyofUsers hol, benzodiazepines) ing useofopioidswithotherdrugs(alco- most opioid-relateddeathsoccurfollow- blood borne viruses (HIV, viruses blood borne HCVandHBV) tions (glomerulonephritis) monia, osteomyelitis, andrenalcomplica- septicaemia, infective endocarditis, pneu- systemic bacterialorfungalinfections: cellulitis scarring, thrombosis,thrombophlebitis, trauma and/orinfectionofinjectionsites: " " " HBV: Estimated17%fromself-report concern 5 to15%—anareaofincreasing of IDUs;incidencerateapproximately HCV: Prevalence(HCV Ab +ve)64% 0.8%) IDUs thusfar(prevalenceratesof HIV: hasbeencontained in Australian Figure 9–1overleaf. for dependentheroinusersas illustrated in There aretwotreatmentpathways available INTERVENTION STRATEGIES MANAGEMENT AND Community Harms Social and problems. sought for clientswithsevere orpersistent however, assessmentshouldbe psychiatric without theneedfor treatment; psychiatric pendence (e.g. methadone maintenance) subside following managementofheroinde- to establish. Psychologicalproblems can ship isoftencomplex andcausalitydifficult ideation andpoorself-esteem. This relation- cidence ofdepression,anxiety, suicidal Dependent heroinusershaveagreaterin- Psychological Harms terventions forlastingbenefits. in- long-term a chroniccondition,requiring use.changes indrug Heroindependenceis withdrawal alonerarelyresultsinlong-term the stressofheroindependence; however, Withdrawal alleviate cantemporarily muchof Objectives WITHDRAWAL SERVICES economic costtothecommunity stigma for individuals, families, friends parenting,friendships) activities (work, impaired functioning/retractionfromother financial, legalproblems Chapter 9 somatic complaints. Provide: may reducetheseverityety which,inturn, of carecansignificantly reduceanxi- Supportive care Supportive general orpsychiatrichospital). settings (e.g.inpatientdetoxificationunits, quire moreintensiveresidentialwithdrawal nificant medicalorpsychiatriccomorbidityre- community withdrawal unit). Clients withsig- drawal (e.g. may requireresidentialsupport ments orrepeatedfailure atoutpatientwith- ices). Clientswithunsuitable homeenviron- (outpatient orhomebasedwithdrawal serv- Withdrawal canusuallybeattemptedathome Setting orcomplex medicalpresentations). atric entations (e.g. dependence, psychi- polydrug recommended for patientswithcomplex pres- Referral toorconsultationwithaspecialistis Assessment Key Components

tions withthefollowingobjectives: Withdrawal servicesareshort-terminterven- ship issuesuntilafterwithdrawal complex personal,emotionalorrelation- to maintainmotivation. Defer addressing patient copewithsymptoms, cravings and counsellingaimedathelping supportive medication for copingwithsymptoms, andtheroleof ration ofwithdrawal symptoms, strategies regardingthenatureanddu- information services facilitate linkagestopost-withdrawal use drug ofheavy andregular apattern interrupt (e.g. overdose) prevent thedevelopmentofcomplications drawal alleviate thediscomfortofheroinwith- 125

Opioids Opioids 126 Treatment pathwaysfordependent heroinusers Figure 9–1 days, monitoring: worker atleastdailyduringthefirstfew review and Patients shouldbereviewedbya health monitoring Frequent including sideeffects use of, andresponseto, medication(s) sons identifiedby use thepatientfor drug use ofheroinandotherdrugs,rea- by theuseofwithdrawalscales) severity ofwithdrawal(canbefacilitated complications ordifficultiesencountered general progress, ongoingmotivation, welfare issuesmayberequired dation, personalsafety,orotherurgent crisis interventionaddressingaccommo- Psycho-social interventions (counselling, rehabilitation (counselling, Psycho-social interventions Withdrawal program programs, peerbased) +/- naltrexone treatment Heroin userHeroin treatment entering Post-withdrawal treatmentPost-withdrawal withdrawal include: porary approachesformanagementofheroin withdrawal symptomsandcravings. Contem- Medication canbeausefuladjuncttoreduce Medication opioid antagonists, ally methadone reducing dosesofanopioidagonist,usu- partial opioidagonists—buprenorphine clonidine anti-anxiolytics, benzodiazepines, plaints suchasanalgesics,anti-emetics, medications tomanagesomaticcom- period which aimtoacceleratethewithdrawal Withdrawal from Withdrawal buprenorphine Maintenance substitution maintenance methadone program

such asnaltrexone Symptomatic medicationsforopioidwithdrawal Table 9–5 Opioid Withdrawal Medication Regimesfor Benzodiazepines Other symptomatic medications NSAIDs Quinine agents Antispasmodic agents Antidiarrhoeal Antiemetics heroin withdrawal for Buprenorphine See Table9–7 symptomatic relief Medications offering See Tables9–5&9–6 day), in 2 or3 divided doses; or temazepam 10mg to30 Diazepam 10mg to 30 mg per day (to maximum/ mg 40 • inpatient settings with experienced staff. (tablets not capsules) • • return of normal sleep pattern. Recommend: intoxication, intravenous use, dependence) and/ordelayed For sleep, anxiety. Concerns regardingabuse(overdose, food p.r.n. For muscle and joint pains. Ibuprofen 200-400 mg t.d.s. with (blindness, severe liver disease). 300 mg i-iinocte p.r.n. For skeletal muscle cramps. Potentially toxic in high doses 10 mg t.d.s.p.r.n.(upto7days). May helpsevereabdominal cramps. Hyoscine butylbromide Diphenoxylate i-ii b.d. p.r.n. for up to 5 days. These may be useful during the first twoto three days. 10 mg t.d.s.) Use reducing doses over 3 to 7days (

Chapter 9 do not continue beyond 7 to 10 days. (regular dispensing/responsible carer) limit access tomedication alcohol) beware of multiple sedatives (e.g. clonidine, heroin, nocte. Higher dosesmayinbe used using opioidantagonists Accelerated withdrawal See Table9–9 heroin withdrawal Methadone for See Table9–8 e.g. metoclopramide 127

Opioids Opioids 128 Symptomatic medicationsforopioidwithdrawal:clonidine Table 9–6 (diarrhoea, nausea, abdominal cramps, sweating, rhinorrhoea); but less effective for Dosing regimes Dosing Hypotension (experienced as dizziness, fainting,light- Side effects contraindications Precautions, (risks of overdose/abuse). sleep disturbances, aches, cravings. Limit access to large amounts of medication Clonidine ( Clonidine α -adrenergic agonist) effective in reducing ‘autonomic’ features given in 3or 4divided doses The maximum daily dose of clonidine = 12mcg/ day, /kg 6: Day Thetotal dose is reducedtheday to75%of 5: Day Day 4: Days 1–3: given in 3or 4divided doses. The maximum daily dose of clonidine = 12mcg/ day, /kg hypotension. inpatient settings. Omit/reducedoseexperiencing ifpatient is doses (to maximum 15mcg / kg / day) canused be in recommended outpatient regime is shown below. Higher patient’s withdrawal severity and adverseevents. A Treatment requires upward dose titration accordingtothe arrhythmias (bradycardia) following clonidine overdose. headedness), fatigue, lethargy, sedation, dry mouth. Severe hypersensitivity. established. Contraindications: severe other CNS sedatives. Safety in pregnancy and lactation not depression, cerebrovascular disease, renal disease,withor unsupervised use not recommended. Usewithcaution in Use only if patient closely monitored ( 3 dose and given in 1or 2doses. The total dose is reducedtheday to25%of 3 dose and given in 2or 3 divided doses. The total dose is reducedtheday to50%of 3 dose and given in 3or 4 divided doses. • • clinical response: Titrate dose of clonidine according to

(450–600 mcg /day). 1 x150 mcg 3or 4 times / day for patients > 60 kg (body weight): (300–400 mcg /day) 1 x100 mcg 3or 4 times / day for patients < 60 kg (body weight): bradyarrhythmia, e.g. daily) — Buprenorphine forheroinwithdrawal Table 9–7 • weeks to (similar methadone reduction programs). Issues include: short-term regimes (e.g. 3 to 10 days); or in gradual reduction regimes over several Buprenorphine ais opioid partial agonist useful inmanaging heroin withdrawal, in either • • • • regimes outpatient Short regimes inpatient Short

features ofopioid withdrawal (or atleast 6–8 hours after last heroin use). who has recently used heroin — dosefirst should be delayed until patient has days. The buprenorphine initial dose can precipitate opioid withdrawal in a person opioid-like side effects (usually mild and tolerable) are common duringfew first and it is dispensed andit undersupervision anauthorised at pharmacy. an authorised medical practitioner requires a permit to prescribe buprenorphine, other medicationsother for opioid withdrawal are not routinely required. this generallythis is greater with longer durations of buprenorphine treatment. some patients experience will ‘rebound’ withdrawal on stopping buprenorphine — rehabilitation. maintenance buprenorphine, (b) naltrexone treatment or ‘drug-free’ (c) a range of post-withdrawal treatment options available, including (a) transfer to Day 8 0 to 1 mg 1 to 0 mg 2 to 0 mg 4 to 0 8mg 0to 2 to 12 mg mg 16 to 4 4 to 12 mg 8mg 4to 8 Day 4 mg 7 Day 8 mg 6 Day mg 10 Day 5 8 mg Day 4 6 mg 3 Day Day 2 Day 1 Day 5 2 mg p.r.n. 0 to 2mg 0to no dose mg 4 to 0 no dose 2 mg p.r.n. Day 7 2 mg mane2 mg p.r.n.; evening p.r.n. Day 6 mg 4 2mg mane, additional with evening Day 5 4 Day 4mg 2 4mg mane,to additional with Day 3 4mg & withdrawal, onset of additional at Day 2 Day 1 rpsdrgm Recommended lower Proposed regime rpsdrgm Recommended lower Proposed regime dose p.r.n. p.r.n. dose evening 4mg2 to evening dose p.r.n. Chapter 9 Dosing regimes and upper limits 4 to 6mg4 to 8mg4 to 8mg4 to and upper limits 129

Opioids Opioids 130 Methadone forheroinwithdrawal Table 9–8 efficacy suggests: treatment. Theevidenceregardingtheir from heroinormaintenancesubstitution pendent heroinusefollowingwithdrawal These aimtopreventrelapsebackde- interventions Psychosocial Interventions Post-withdrawal help groups cluding therapeuticcommunities),self- long-term residentialrehabilitation(in- more structuredinterventionssuchas or cognitivefunctioningmaybenefitfrom those withoutgoodcommunitysupports and higherlevelsofeducation employment), goodcognitivefunctioning social supportsystems(e.g.relationships, effective forthoseindividualswithgood outpatient counsellingprogramsaremore regimes Dosing • include: weeks.Issues over reduction gradual with regimes longer or days), 14 7to (e.g. regimes short in used be can Methadone • • •

few days. mild (usually effects side opioid-like and it is dispensed under supervision at an authorised pharmacy. authorised atan supervision under dispensed and itis methadone, prescribe to permit a requires practitioner medical an authorised limits the use of methadone in inpatient settings. inpatient in ofmethadone theuse limits This days. several for continue can and methadone, their ceases patient the after when/soon experienced discomfort greatest dose, with methadone in generally withdrawal discomfort sedating drugs (benzodiazepines, alcohol). (benzodiazepines, drugs sedating using other about Caution ofvalue. maybe symptomatic medication of courses short when dose, methadone their has reduced patient the until required routinely not are withdrawal opioid for medications other regime). day 10 day for per mg 25 mg, by2.5 start (e.g. regime reduce of duration toproposed Dose conditions). according is reduced medical concomitant and dependence level ofphysical upon (depending 30mg 20and between with doses Commence and tolerable) are common during first during common are and tolerable) creases as the patient reduces their reduces as patient creases the lor iscritical. the relationshipbetweenclientandcounsel- As inmostformsofcounselling,thequality drug treatmentagenciesaimingto: prevention isacommonapproachusedby havioural orpsychodynamictheory.Relapse ples ofsupportivecounselling;cognitive-be- ily based,andmaybestructureduponprinci- Counselling canbeindividual,grouporfam- counselling Outpatient 3 year) residentialprograms inwhichdrug These areusuallylong-term(e.g.6monthto communities Therapeutic to deal with these risk factorsto dealwiththeserisk develop cognitive-behavioural copingskills factors use associatedwithrelapsetodrug identify environmentalandpsychological enhance commitmenttoabstinence and ‘community’,butdoesnotappealtoall. drug usersasitprovidesasupportstructure nence philosophyandisattractiveforsome in Australia.Itoperatesona12-stepabsti- help groupforopioiddependentindividuals Narcotics Anonymous(NA)isthemainself- groups Self-help munity re-entryarehigh. long-term; althoughratesofrelapseoncom- for thosepreparedtoremainintreatment legal conditions.Thisisaneffectiveapproach orresources, oftenwith community supports usinglifestyles,highly entrencheddrug few communities tendtoattractindividualswith counselling andrehabilitation. Therapeutic environment, withvaryingapproachesto users moveintoahighlystructured,isolated aspects Clinical opioids. antagonist thatblocks theactionsofother dependent patients. Naltrexone isanopioid prevention ofrelapsefor heroinoralcohol Naltrexone isregisteredinAustraliaforthe Naltrexone Treatment " " treatment outcomescanbeoptimisedby: ceasing suchadose ade effects wear offwithin2to3days of recommended doseis50mgdaily.Block- naltrexone is recommendedpriortostarting withdrawal —analoxonechallengetest naltrexone treatmentresultsinsevere to startingnaltrexone.Premature use, 10dayswithoutmethadone)prior drawal (atleast5to7dayswithoutheroin clients shouldcompleteopioidwith- treatment team member) andclosemonitoring by supervision ofdoses(e.g.byafamily chosocial treatmentprogram participation inacomprehensivepsy- Chapter 9 cravings andreducingtheeuphoric effectsof thereby preventingwithdrawal, reducing or buprenorphine)thatsubstitutes forheroin users withalong-actingopioid (methadone The rationale istosupplydependentheroin and Outcomes Rationale, Objectives OR BUPRENORPHINE TREATMENTMETHADONE WITH SUBSTITUTION MAINTENANCE ordered individuals). for abstinence(e.g. professionals, court- non-drug users,andhavestrongmotivation support networks,areinrelationshipswith those whoareemployed,havegoodsocial carefully selectingclientsfor treatment— Higher successratescanbeachieved by of tion rates-trials ‘street heroinusers’ suggest: Naltrexone treatmentgenerallyhaspoorreten- with associated Outcomes events Adverse naltrexone treatment naltrexone ment at6months 10–20% areretainedinnaltrexone treat- beyond onemonth 40% areretainedinnaltrexone treatment effects ofopioidsfor analgesia toanalgesia:barriers naltrexone blocks the following naltrexonetreatment and possibleincreasedopioidsensitivity naltrexone, duetolossofopioidtolerance creased riskofoverdoseuponstopping however, thereappearstobeanin- occur whilstaclientistakingnaltrexone, overdose: overdoseonopioidscannot ally subsidewithtime the commencementoftreatment,butusu- nal cramps,nauseaarecommonduring mood andsleepdisturbances,abdomi- 131

Opioids Opioids 132 Accelerated withdrawalusingopioidantagonists Table 9–9 treatment at1year. Ofthese: mencing methadonetreatmentareretainedin approximately 50–70%ofheroinusers com- functioning. Australian researchsuggeststhat and criminality, andinimproving psychosocial heroin usersinreducingmortality, heroinuse This isaneffective treatmentmodalityfor most cific objectives are: selves fromadrug-usinglifestyle.Thespe- stop usingheroin,andtodisassociatethem- continued heroinuse.Thisenablesclientsto use heroin regularly (e.g.use heroinregularly daily) approximately onesixthwillcontinueto (e.g. weekly) heroin atamarkedly reducedfrequency approximately onethirdwillcontinuetouse heroin approximately halfwillnolongerbeusing tivity ents, includingareductionincriminalac- to improvethesocialfunctioningofcli- viruses to reducethetransmissionofbloodborne to reducemortality being ofclients to improvethegeneralhealthandwell- clients useby to reduceheroinandotherdrug Australia for this indication, and specialist consultation is recommended. although research is yet to establish such benefits. Naltrexone is not registered in earlyandwithdrawal inductionnaltrexone onto enhances long-termoutcomes, sedation in highly supervised (hospital) setting. It is postulated that more rapid involves inducting the patient onto antagonists using general anaesthesia or heavy medications (clonidine, benzodiazepines, anti-emetics). Ultra-rapid detoxification withdrawal. Rapid detoxification involves the use of naltrexone and symptomatic Naloxone and naltrexone accelerate the onset and reduce the duration of opioid rable efficacywhenusedinequivalent doses. areofcompa- Methadone andbuprenorphine nance programs when: Treatment outcomesareenhancedinmainte- Treatment inAustralia Delivering Substitution ling andotherpsychosocialinterventions where theclientparticipatesincounsel- and providers; between theclientandservice there isagoodtherapeutic relationship (e.g.buprenorphine 12–24mgdaily) done (e.g. 60–120mgdaily)or clients areonadequatedosesofmetha- and associatedlifestyles have distancedthemselvesfromheroinuse encouraged toremainintreatmentuntilthey of time(>12months).Clientsshouldbe clients remainintreatmentfor longperiods buprenorphine dividual clientswithmethadone or totreatin- doctors mustreceive apermit practitioners requires atrainingprogram for medical governments.or territory This generally by state cies orclinicsspeciallyauthorised tomedicalpractitioners, pharma- stricted maintenance substitutiontreatmentisre- needs oftheindividualclient. canbebettertailoredtothe Buprenorphine Substitution Treatment Problems withMaintenance ment stigma associatedwithmethadonetreat- havea minority persistent sideeffects rates uponthe cessationoftreatment withdrawal syndromeandhighrelapse dispensing the costtoclientsofsupervised pensing the inconvenience ofdaily/regulardis- complex presentations towards managingclientswithmore Public clinicprograms arebeingoriented ment andincreasingitsaccessibility. pharmacies, therebynormalisingtreat- by generalpractitionersandcommunity treatment isincreasinglybeingdelivered risdiction) ineachju- oftime(policiesvary a period ceive anumberoftake-awaydosesafter clinic orpharmacy.Stableclientscanre- ata isusuallysupervised buprenorphine the administrationofmethadoneand Chapter 9 Buprenorphine Treatment Effective Methadone/ Principles ofSafeand ventions andreferraltospecialistservices increased monitoring,psychosocialinter- (e.g. continuedhighriskdruguse)require clients whoarenotrespondingtotreatment ofoverdoserisk fromdropintolerance torecommencingtreatment— doses prior (> 3)consecutive methadone/buprenorphine review clientswhohave missedmultiple treatmentprovideran experienced should to anincreasedoverdose risk tives (e.g. alcohol,benzodiazepines), due beware ofcombineduseotherseda- " " " accordingly: inductionandtitrate dose frequently during commence withlowdoses,reviewclient pendent people treatment areonlysuitable for opioidde- treatment. Methadone/buprenorphine tocommencing consent isrequiredprior comprehensive assessmentandinformed experienced treatmentprovider only increasedoseafterreviewbyan transferring frommethadone buprenorphine, especiallyinclients tated withdrawalonstarting opioid withdrawal.Bewareofprecipi- buprenorphine doseuntilclientisin greater than8mg),anddelayfirst usually between4and8mg(never starting dosesofbuprenorphineare 4 days eral onlyincreasedoseafterevery3– methadone duringinduction—ingen- 40 mg).Bewareofaccumulation ally between20to30mg(andnever> starting dosesofmethadoneareusu- 133

Opioids Opioids 134 Palmer, B.2001, NDARC (nodate), Gowing, L.,Ali,R.&White,J.2000,‘Themanagementofopioidwithdrawal’ Lintzeris, N.,Dunlop,A.&Thornton,D.1996, Young, R.,Saunders,J.Hulse,G.,McLean,S,Martine, J. &Robinson,G.2002,citedin NDARC (nodate), Gill, T.&Evans,M.1996, Dunlop, A.,Thornton,D.Lintzeris,N.,Muhleisen,P.,Khoo,K.&Lew,R.1996, Gill, T.1997, CDHA 2002, Alliance ofNSWDivisionsGeneralPractice: RESOURCES Dale, A.&Marsh,2000, Research Centre,Sydney. search Centre,Sydney. ‘Opioids’, ch.6,OxfordUniversityPress,SouthMelbourne, Victoria,pp.79–123. supp2.pdf Alcohol SupplementNo.2,www.health.nsw.gov.au/public-health/dpb/supplements/ Ageing, Canberra. Hulse, G.,White,J.&Cape,G.(eds.)2002, Step SpecialistDrugandAlcoholServices,Mt.Lawley,Western Australia. Point AlcoholandDrugCentreInc.,Fitzroy,Victoria. www.health.nsw.gov.au/public-health/dpb/supplements/supp8.pdf Working Group,Perth. to Assist in the Treatment of Patients Withdrawing from Alcohol and Other Drugs, Drugs, Other and Alcohol from Withdrawing Patients of Treatment the in Assist to and Other Drug Interventions, Drug Other and Alcohol Review Alcohol Methadone www.answd.com.au Illicit Drug Training for Pharmacists for Training Drug Illicit ,

Turning PointAlcoholandDrugCentreInc.,Fitzroy,Victoria. Alcohol and Drug Withdrawal: A Practical Approach. A Manual for Doctors for Manual A Approach. Practical A Withdrawal: Drug and Alcohol Heroin Addiction Heroin What You Need to Know about Methadone about Know to Need You What Heroin , vol.19,pp.309–318. , ReachoutFactSheet–‘Drugs’,NationalDrugandAlcoholRe- Methadone in the Treatment of Opioid Dependence Opioid of Treatment the in Methadone A Summary of the Evidence Based Practice Indicators for Alcohol for Indicators Practice Based Evidence the of Summary A BestPracticeinAlcoholandOtherDrugInterventions , GPDrugandAlcoholSupplementNo.8, Getting Through Heroin Withdrawal Heroin Through Getting Management of Alcohol and Drug Problems, Drug and Alcohol of Management , CommonwealthDepartmentofHealthand ,

National DrugandAlcohol ,

GP Drugand Coming Off Coming Drug and Drug ,

Turning Next National Seroprevalence StudyofUsersNeedleExchangePrograms, 2001. REFERENCES Chapter 9 135

Opioids Opioids 136 Substances Volatile Chapter 10 Volatile substanceusemay be: ness orcauseintoxication. off fromasubstanceatambienttemperaturetoalterconscious- Volatile substanceuseisthedeliberateinhalationofvapourgiven when exposed toair. V used areamylnitriteandnitrousoxidefoundincanisters. 10–1 liststhemajorvolatile substances andtheirsources. Also spray paints, gluesandpaintthinnerscontainingtoluene. Table containingbenzenelacquers andvarnishes andadhesives, The mostcommonlyusedvolatile substancesincludepetrol, SUBSTANCES COMMONLY USEDVOLATILE

chronic —anhabitualanddominantactivity recreational —frequentlyagrouppractice experimental —usingoutofcuriosity rapidly changefromaliquid,orsemisolidstatetovapour (CNS) depressantsandarechemicalcompoundsthat OLATILE substances arecentralnervoussystem 137

Volatile Substances Volatile Substances 138 Major volatilesubstancesandtheirsources Table 10–1 1990). (Henretig,1996;and maintaineuphoria Linden, vapour concentrationavailability andachieve progress tohuffingandbagging toincrease Chronic usersgenerally beginwithsniffingand stance administration: There arethreemajormodesofvolatile sub- MODES OFADMINISTRATION

held mouth ornose. Inextreme casesmay be monly apieceofclothing)heldagainstthe and nose overor paperbagheldfirmly themouth pours directlyintothemouth bagging huffing sniffing the surroundingair with asignificantquantitydissipatedinto container. Lowest vapour concentration, • ao oaiesbtne Sources Major volatile substances • • • • • • • • • • •

in in benzene toluene xylene propane butane acetone n-hexane trichloroethane trichloroethylene trichlorofluor dichloromethane butyl nitrite : (com- Apieceofsaturated material : Vapours inhaleddirectlyfroma the mouth. Spraying aerosolva- : Vapours inhaledfromaplastic omethane • • • • • • • • • • • •

emerging: some trendsinusingvolatilesubstancesare community groupsandsubgroups. However on theprevalence ofuseamongstgeneral There isalack ofgoodepidemiological data PREVALENCE petrol, varnish, resins, lacquer thinners adhesives,spray paints, glues,paint lacquer, thinner, wood glues bottled fuel cigarette lighter fluid lighter cigarette nail polishremover model glues, rubber cement dry cleaning agents, degreasing agents degreasing agents dry cleaning agents, stain removers, aerosol propellant paint stripper room air freshener (Boys etal.,1997) phetamine orLSDatrave scenes commonly combinedwithecstasy,am- substances andcannabisweremost amongst recreationaldrugusersvolatile adolescents (AIHW, 1999) male adolescentsusemorethanfemale (White, 2001) younger teenagers, aged12andover the trendforuseisgreatestamongst (White, 2001) 14–17 year oldage groupthanolderadults there isahigherprevalenceamongstthe Volatile substances: APPEAL nervous system centralis absorbedintofat,includingthe minutes thenrapidlydecreaseasthedrug Following use, bloodlevelspeakwithin Acute Effects PHYSICAL COMPLICATIONS Common initialeffects are: ues inasoberstate dulge andthengohomeortootherven- pearance ofintoxication. The usercanin- create rapidintoxication andrapid disap- ily concealed containers (e.g. cansorbottles)and eas- can bepackaged insmallanddiscrete their saletominors number ofAustralian Statestopreclude cars andoffices, despitelegislationina hardware stores, homes, building sites, are readilyavailable fromsupermarkets, are relatively inexpensive young Indigenoususers parts, compared withnon-Indigenouscounter- (Carroll etal.,1998) a senseofinvulnerability exhilaration excitation euphoria " " " use overalongerperiod use morefrequently show greaterhabitualuse (CNS). Chapter 10 (Lolin, 1989). functioning, whichcausesCNSdepression generalised reductionofnervemembrane cells.tissue includingnerve This resultsin readily absorbedfromtheblood intohighfat System ofsolvents arefatThe majority soluble and Nervous Central Specific Physical Effects Central nervoussystemdepressionleadsto: Effects atHigherDoses Users mayalsoexperience: Negative AcuteEffects and muscleabdominalcramps. toms commonlyincludeheadache, nausea achieve thedesiredeffect. Withdrawal symp- quires asignificantincreaseindoseto several days ofrepeatedusetheuserre- ever, tolerancedevelops rapidly andwithin fects areachieved afterafew breaths. How- In thenovice, orinfrequentuser, desiredef- hours (Liiraetal.,1988). These effects commonlyresolve withintwo (Linden, 1990) arrestanddeath coma, cardiopulmonary final stagesassociatedwithseizures, stupor ataxia; followedby then andvisualhallucinations; visual distortions delusions, weakness, tremor, headaches, slurred speech,disorientation,confusion, abdominal pain diarrhoea headaches vomiting nausea 139

Volatile Substances Volatile Substances 140 also becausedby placed in the material tic bagsusedfor bagging. Asphyxiation can cation tooccurfromaspiration ofvomit inplas- It isnotuncommonfor asphyxiation orsuffo- of consciousness. directly damagelungtissueresultinginloss Volatile substancesdisplaceoxygen andcan Lung (Ramsey, Andersonetal.,1989). ofvolatile substanceuse have history noprior from ‘sudden death’ inthesecircumstances 1989). Approximately 20%ofthosewhodie (Shepherd, line causesventricular fibrillation theresultingsuddensergeofadrena- ‘startled’, myocardium toadrenaline. When theuseris taining benzene andtoluene, sensitisethe ple, inaerosols, petroland substancescon- concern. Hydrocarbonscontained,for exam- andcardiacarrhythmiabrillation isamajor fi- Sudden deathassociatedwithventricular Heart (Arnold etal.,1994;Jones&Balster,1998) including: exposure isassociatedwithmalformations readily crosstheplacenta.Neonataltoluene Given theirfat solubility,neonatal volatile substances and Maternal 1983; Williams,1988). atrophy andhearingloss(Fornazzarietal., in peripheralneuropathy(Lolin,1989),optic users. Destructionofnervecellsalsoresults lar damageareobservedinlong-termchronic matter damage,corticalatrophyandcerebel- ene causesthemostCNSdamage.White Of thecommonlyabusedsubstances,tolu- developmental delays prematurity low birthweight foetal growthretardation spontaneous abortion oral cleftsandmicrocephaly and lymphoma (Rosner & Grunwald, 1980). and lymphoma(Rosner&Grunwald, ity andcancerssuchasmyeloma, leukaemia duction, aplasticanaemiaandrelatedmorbid- suppressed functioningofbonemarrow pro- Chronic useofbenzene isassociatedwith (Hutchens &Kung, 1985). andtrichloroethylene use trichloroethane hepatitis withliver dysfunction associatedwith hydrocarbonchlorinated vapours resultintoxic toluene use(Dinwiddie, 1994). and Chloroform and liver failure have beenassociatedwith (Marjot &McLeod,1989). Completekidney ing ofthedistaltubule andcollectingducts tubular acidosisthatinterferes withfunction- marrow bone Compounds containingtoluenecauserenal and liver Kidneys, et al.,1996). towards other usersandnon-users(Dukarm lescent chronicvolatile substanceusers, both ofviolenceamongstado- There arereports cidal thoughts(Howard &Jenson,1999). esteem andassociateddepressionsui- academic problems, activity, criminal low self- living environments, schoolabsenteeism and problems andunstablecohol andotherdrug poorfamily ofal- relations, familyport history stances aremorelikely thannon-userstore- Adolescents whochronicallyusevolatile sub- COMPLICATIONS PSYCHOSOCIAL fires resultingfromcombustion ofinhalants. arealsoassociatedwith bidity andmortality injury, braindamage, traumaanddeath. Mor- behaviourshigh risk thatcancauseaccidents, volatile substanceuseresultsinimpulsive The senseofinvulnerability associatedwith and Mortality Other Morbidity mouth duringhuffing(Linden,1990). of hippuric andbenzoic acidinurine. of hippuric Toluene by elevated useis confirmed levels volatile substancesormetabolites. screeningisnotdesignedtodetect drug Urine may maskthoseofvolatile substances. Symptoms associatedwithpolysubstanceuse also indicateuse. more oftheabove physical symptomsmay aggressioncoupledwithoneor appropriate Excessive moodswings, disinhibitionorin- movement oftheeyes.latory sociated withdecreasedreflexes andoscil- huffer’s rash’. Recentusemay alsobeas- are commonlyreferred toas ‘sniffer’s or ing skinlesionsaroundthemouthandnose spots)orpusproduc- of skin(erythematous established. The resultingpatchy redness infections tobecome may bacterial permit and and facial skinwhichcauses irritation ofmucousmembranes can leadtodrying val injection(McHugh,1987). Chronicuse wheeze, salivation, sneezing,orconjuncti- increased sputumproduction,cough, mayMucous membrane resultin irritation breath, skinorcontaminatedclothing. cans withsolvent residueorresidualodouron tion ofsolvent containers,orbags, bottlesand symptoms and Recent usemay beindicatedby theidentifica- signs Clinical To detectandassessvolatile substanceuse: Detection andAssessment INTERVENTION STRATEGIES MANAGEMENT AND by amedicalpractitioner conduct athoroughphysical examination obtain acomprehensive history look for indicatorsofrecentorchronicuse Chapter 10 use perse.Informationonthe relationship and raveactivities,thanvolatile substance more likelytobeassociatedwith bodyimage example, inthoseattendingrave dances,is amongst recreationalusers.Socialstatus,for stance useiscommonlyanoptionalactivity Similar toexperimentaluse,volatilesub- Recreational vertently increaseuse. be undertakenwithcareastheycaninad- However, anyeducationalprogramsshould reduce theprevalenceandfrequencyofuse. part ofanintegratedgeneralcurriculummay vided inearlyschoolyears(lateprimary)as death’ isofconcern.Educationinitiativespro- and morbidityislow.Mortalityfrom‘sudden tolerance andassociatedexcessivetoxicity, in thisgroupprecludethedevelopmentof intervention ormajorincident.Patternsofuse tal activities.Itcommonlyresolveswithout event amongstakaleidoscopeofexperimen- Volatile substanceuseisusuallyatransitory Experimental and Chronic Use Experimental, Recreational polysubstance useissuspected. blood screeningmay beindicatedwhere blood countandoxygen saturation. or Urine required. tests includecomplete Laboratory normalities. Hydration withsalinemay be is indicatedinthepresenceofcardiacab- isrequired.monitoring Electrocardiography assessment,stabilisationand opulmonary rate ofvolatile substanceelimination. Cardi- There isnosignificantwaytoenhancethe tion resolves. function shouldbemonitoreduntilintoxica- ronment andobserved. Cardiopulmonary user placedinawellventilated, safe envi- and skinshouldbedecontaminated,the intoxication resolves spontaneously. Clothing In mostinstances, acutevolatile substance Intoxication 141

Volatile Substances Volatile Substances 142 tional testsmay berequiredtoassessthepres- and blood urea,nitrogen and creatinine. Addi- electrolytes,count, oxygen saturation,serum ity. testsincludecompleteblood Laboratory morbid- where thereisevidence ofpulmonary nation arenecessary. Chestx-rays arerequired Mental state, organandneurologicalexami- for care and Assess evaluation.pirical The objectives hereareto: em- Management isdifficultandlacks rigorous management Long-term quency ofuse. drugs mayreducetheprevalenceandfre- trayal ofvolatilesubstancesasalowclass experimental andrecreationalusers,thepor- amongst ‘rave’users,isnecessary.Forboth stimulant use),bothpopularactivities raise adrenalinelevels(e.g.exertionandco- the avoidanceofuseandco-activitiesthat death isarealpossibilityandinformationon and quantityofuseinthisgroup.Sudden mortality willlikelydecreasethefrequency between use,toleranceandmorbidity medical complications medical abuser chronic the — terns andassociatedlifestyles terns move theuseraway fromchronicusepat- associated withuse minimise harm assess andcarefor medicalcomplications acute andchronictissuetoxicity anddamage. the development oftolerancetoreduceoverall moval oflead-basedpetrolandeducationabout use ofplasticbagsthatcauseasphyxia, re- isrequired.and mortality For example, non- minimisation toreducemorbidity Here harm ofremoval communities, oftheuser.risk short use with objective, thismay beinitiallyimpracticalinhigh associated Although totalabstinencemay betheoptimal harm Minimise associated with: Use intheseenvironmentsisoftenclosely ban orIndigenouscommunities). volatile substanceusetakesplace(e.g.ur- on thecommunityandenvironmentinwhich et al.,1998).Overall,initiativesshouldfocus cant factorinreducinguse(Carroll,Houghton been identifiedbychronicusersasasignifi- resulting fromvolatilesubstanceusehas and habitual Exposure tothosewithsignificantmorbidity, from away user the Move to otherorgans(e.g.kidneys). ence ofmetabolicdisturbancesandmorbidity chronic use patterns use chronic est quantitiesofvolatile substances group uponthose whoconsumethegreat- ofgreaterstatuswithinthe the conferring poor economicprospects a lacksocialactivitiesand ofalternative healthy lifestyle acquisition(CDH,1985). initiatives andtargetingsocialskills withprograms utilisingpeersupport reported effective. Somemodestsuccesshasbeen factual educationprograms are suggests thatmassmedia,fear tacticsand be considered. Limitedavailable information schoolsshould vention initiatives atprimary orpre-teenyears, pre- use inearly soearly Many volatile substanceuserscommence PreventionPrimary Strategies and supportmayberequired. munities. Communityandfamilycounselling developed incollaborationwithlocalcom- sential. Initiativesshouldbeacceptabletoand social statusoutsidetheusergrouparees- Providing bothdesirablesocialactivitiesand Chapter 10 not hugely 143

Volatile Substances Volatile Substances 144 CDHSH (Commonwealth,DepartmentofHumanServicesandHealth)1994, Youth (2000) SubstanceAdviceService RESOURCES Baker, A.,Boggs, T. &Lewin, T. 2001, cognitive– ofbrief ‘Randomised controlled trial pp. 1279–1287. 1992 behavioural amongstregularusersofamphetamine’, interventions School Students’ Drug Use: Comparison of Patterns in Victoria and New South Wales South New and Victoria in Patterns of Comparison Use: Drug Students’ School , Canberra,ACT. www.ysas.org.au/drug/chroming Chroming (Inhalant Use) The Facts The Use) (Inhalant Chroming Addiction . Fitzroy, Vic. Secondary , vol. 96, , CDH, (CommonwealthDepartmentofHealth)1995, Dinwiddie, S.1994,‘Abuseofinhalants:areview’, Arnold, G.,Kirby,R.,Langendoerfer,S.&Wilkins-Haug,L.1994.‘Tolueneambryopathy: Henretig, F. 1996, ‘Inhalant abuse in children and adolescents’, Henretig, F.1996,‘Inhalantabuseinchildrenandadolescents’, Boys, A.,Lenton,S.&Norcross,K.1997,‘PolydruguseatravesbyaWesternAustralian AIHW (Australian InstituteofHealth& Welfare) 1999, REFERENCES Liira, J.,Riihimaki,V.&Pfaffli,P.1988,‘Kineticsofmethyl ethylketoneinman:absorption, Linden, C. 1990, ‘Volatile substances of abuse’, Linden, C.1990,‘Volatilesubstancesofabuse’, Dukarm, C.,Byrd,R.,Auinger,P.&Weitzman,M.1996,‘Illicitsubstanceuse,gender,and Hutchens, K.&Kung,M.1985,‘“Experimentation”withchloroform’, Fornazzari, L.,Wilkinson,D.A.,Kapur,B.M.&Carlen,P.L.1983,‘Cerebellar,corticaland Howard, M.&Jenson,J.1999.‘Inhalantuseamongantisocialyouth:prevalenceand Carroll, A.,Houghton,S.&Odgers,P.1998,‘VolatilesolventuseamongWesternAustralian Lolin, Y.1989,‘Chronicneurological toxicityassociatedwithexposuretovolatilesubstances’, Jones, H.&Balster,R.1998,‘Inhalantabuseinpregnancy’, clinical delineationanddevelopmentalfollow-up’, 319–329. sample’, Human Toxicology Human distribution andeliminationininhalationexposure’, the riskofviolencebehavioramongadolescents’, functional impairmentintolueneabusers’, correlates’, adolescents’, vol. 8,pp.559–578. Medicine Survey: First results First Survey: Clinics of North America North of Clinics Survey, Occup Medicine ational & & ational Canberra. , vol.150,pp. 797–801. , vol.78,pp.715–718. Drug and Alcohol Review Alcohol and Drug Addiction Behaviour Addiction Adolescence Environ , vol. 8,pp. 293–300. , AIHWcat. no. PHE15,AIHW, Canberra. Chapter 10 , vol.25,pp.153–167. mental mental , vol.33,no.132,pp.877–888. vol.24,pp.59–74. Health , vol.16,pp.227–234. , vol.60,pp.195–200. Emerg Acta Neurologica Scandinavica Neurologica Acta 1998 National Drug Strategy Household Strategy Drug National 1998 Addiction ency Medicine Medicine ency Archives of Pediat of Archives National Drug Strategy Household Strategy Drug National Pediatrics Pediatr Ann Pediatr , vol.89,pp.925–939. International International Obstetrics & Gynecology & Obstetrics ,

vol. 93,pp.216–220. Clin ics of of ics American Journal of Journal American , vol.25,pp.47–52. rics & & rics North Am North , vol.67,pp. Arch Adolescent ives of ives erica , 145

Volatile Substances Volatile Substances 146 Rosner, F.&Grunwald,H.1980,‘Cytotoxicdrugsandleukaemogenesis’, Marjot, R.&McLeod,A.1989,‘Chronicnon-neurologicaltoxicityfromvolatilesubstance Williams, D.1988,‘Hearinglossinagluesniffer’, McHugh, M.1987,‘Theabuseofvolatilesubstances’, Ramsey, J.,Anderson,H.,Bloor,K.&Flannagan,R.1989,‘Anintroductiontothepractice, Shepherd, R.1989.‘Mechanismofsuddendeathassociatedwithvolatilesubstanceabuse’, White, W.‘Australiansecondarystudents’useofover-the-counterandillicitsubstances vol. 8,pp. 261–269. abuse’, vol. 34,pp.333–340. 321–324. Human Toxicology Human prevalence andchemicaltoxicologyofvolatilesubstanceabuse’, in 1999’,citedMiller,M&Dapper,G.2001, Haematology 2000 , no.8,AustralianInstituteofHealthandWelfare. Human Toxicology Human , vol.9,pp.663–681. , vol. 8,pp. 287–291. , vol.8,pp.301–306. Journal of Otolaryngology of Journal Statistics on Drug Use in Australia in Use Drug on Statistics Pediatric Clinics of North America North of Clinics Pediatric Human Toxicology Human , vol.17,pp. Clinical , , Benzodiazepines Chapter 11 motor incoordination,decreasedreactiontimeandataxia). use resultsinperformancedeficits(includingmemoryimpairment, anticonvulsant, hypnoticandmusclerelaxantproperties.Their Benzodiazepines areCNSdepressants.Theyhaveantianxiety, inthe1970sand1980s. drugs classof tobecomethemostcommonlyprescribed popularity introduction ofmany relatedcompoundsthatachieved immense as asafe tobarbiturates. alternative This was followed by the first benzodiazepine (chlordiazepoxide) was marketed in1959 PHARMACOLOGY B in anaestheticpracticebutalso asa‘daterape’drug).Theyare water solubleare poorly withtheexception ofmidazolam (used Benzodiazepines arerelatively lipophilic(fat soluble) andmost ABSORPTION complex (Capeetal.,2002). Benzodiazepines bindtoreceptorsontheGABA–Areceptor (GABA) whichisthemaininhibitoryneurotransmitterin CNS. Benzodiazepines enhancetheeffects acid ofgamma-aminobutyric also widely used for illicit or non-prescribed purposes.also widelyusedfor illicitornon-prescribed The clinical practicefor sedationandreliefofanxiety. They are ENZODIAZEPINES are minortranquillisers widelyusedin Chapter 15 147

Benzodiazepines Benzodiazepines 148 PATTERNS OFUSE effects (especiallywithchronic dosing). resultinginprolonged than theparentdrug Active metabolitesmay have longerhalf-lives glucuronidation whichinactivates them. may produceactive compounds, andby They aremetabolisedby bothoxidation, which soluble compoundsbefore renalexcretion. Benzodiazepines must towater beconverted METABOLISM (Therapeutic GuidelinesLtd.,2000). depression, hypotonicity andwithdrawal can resultinneonataldrowsiness, respiratory tissue. and They allcrosstheplacentalbarrier tolessvascularare thendistributed adipose Benzodiazepines rapidly entertheCNSand DISTRIBUTION e.g. oxazepam(Capeetal., 2002). than therelatively morehydrophilic agents agents e.g. diazepam areabsorbedfaster 2 hoursafteringestion. The morelipophilic with peakplasmaconcentrations from½to generally rapidlyandfullyabsorbedorally or over had the highest proportion ofpeople or over hadthehighest proportion across agegroups,peopleaged 40years these drugs(3.0%and2.2%respectively) likely thanwomenofthe sameagetouse F: 1.0%), menaged20–29were more use between menandwomen(M: 1.2%; prevalence oftranquilliserorsleepingpill while thereislittleoveralldifferencein ported amongstthoseaged20–29years withpeakusere- non-medical purposes, sleeping pillsintheprevious 12months for useoftranquillisersor or over reported in 2001,1.1%ofAustralians aged14years

(Victoria Police,2002;Capeet al.,2002) Short-term Effects All aresedating,anxiolyticandanti-convulsant. BENZODIAZEPINES EFFECTS OF common useofbenzodiazepineslong-term remains with age benzodiazepines increasesmarkedly the useofnight-timesedationwith prescriptions) RPBS, privateandunderco-payment pharmacies in1998(includingPBS/ were dispensedthroughAustralian million prescriptionsforbenzodiazepines Medicines (PBS, 1998),atotalof8.89 according totheAustralianStatisticson week (AIHW,2001) every day,non-medical purposes orevery who reporteduseofprescriptiondrugsfor of respiratorydepression alcohol andopioidsincreasing likelihood potentiation ofotherCNSdepressants e.g. feel ‘invulnerable, invincible andinvisible’) behaviour (especiallyhighdose, usersmay ness, hypomania andextreme disinhibited paradoxical excitement, euphoria, restless- headaches mouth blurred vision,dry slurredspeech dysarthria, nystagmus, vertigo depression muscle weakness orhypotonia confusion cially anterograde amnesia) (espe- impaired cognitionandmemory time andataxia motor incoordination,decreasedreaction drowsiness, lethargy, fatigue psychiatric disorders. tremens), epilepsy, tremorandagitationin ment ofalcoholwithdrawal (toprevent delirium Other usesinclinicalpracticeincludethetreat- antidepressants. to thebarbituratesortricyclic andrelative safety compared the short-term, insomnia becauseoftheirefficacy, atleastin Clinically usefulinthetreatmentofanxietyand Uses USES ANDPROBLEMS (Cape etal.,2002) organ toxicity) plus: Similar toshort-termeffects(withnoknown with Benzodiazepines Problems Associated Long-term Effects weeks attherapeutic doses) dependence (may develop after3–6 ment menstrual irregularities,breastengorge- arousal) mal highsorgriefduetoinhibitionof emotional blunting(inabilitytofeelnor- and effects onmemory) tolerance develops toanxiolyticactions motor effects (conflictingevidence whether tolerance tosedative/hypnotic andpsycho- but poorerqualityofnight-time sleepcom- benzodiazepines haveasimilar quantity onstrated thatinsomniasufferers whouse people withsleepingdisorders have dem- adverse sleepeffects.Studiesamongst ing oroperatingmachinery 1990). whendriv- Advisepatients ofrisks ofaccidents(Osteretal., creased risk andin- sedation, cognitive impairment, diazepine useisassociated withexcess ofbenzo- patterns orlong-term short- Chapter 11 HIGH RISKGROUPS

elderly: tion oraggression emotionsorunwanted stimula- perience adverse moodeffectswithinabilitytoex- polydrug andinjectingusers: " " " " (Busto etal.,1986)(i.e., within3–6weeks) even whenrecommendeddosesareused dependence andwithdrawalcanoccur creases theriskofoverdose benzodiazepines, alcoholoropioids, in- polydrug use,orconcurrentuseof benzodiazepines somnia frequentlyoccursoncessationof pared withnormalsubjects.Reboundin- half-life ofsomedrugs (Ashton, 1991)orduetotheshort to coverincreasedtolerance patient avoidsincreasingthedose medication, possiblybecausethe parent whilethepatientisstilltaking withdrawal symptomsmaybeap- tremely disinhibited,oruncharacter- polydrug users,mayresult inex- high-dose use,particularlyamongst and/or dependence creased riskofnegativesideeffects medications placesthepatientatin- diazepines incombinationwithsome chronic disease.Useofbenzo- cations forthemanagementof are higherusersofprescribedmedi- accidents oversedation andincreasetheriskof doses canreadilycause tion verydifficult.Accumulationof sleep aidandthereforefindcessa- pendent onbenzodiazepinesasa elderly patientshavebecomede- 1999). Throughlong-termuse,many amongst theelderly(Leipzigetal., higher riskoffallsandfractures Chapter 15 149

Benzodiazepines istic behaviour. Described as the To reduce access and harm resulting from the ‘Rambo syndrome’, a person may prescribing of multiple, single, high-dose pre- engage in assaults, shoplifting or scriptions, write short-term prescriptions and other activities, in full view of wit- encourage regular review. There is a high nesses, and be unable to recall any risk associated with prescribing large quanti- events related to the offence ties of benzodiazepines (and other drugs of " benzodiazepine use appears to be in- dependence). creasing amongst injecting drug users, and is associated with a higher Precautions rate of HIV risk-taking behaviour (Darke et al., 1992) Benzodiazepines should be used with caution in patients: " risk of overdose in people using Benzodiazepines heroin is increased when other CNS with renal failure depressants, such as alcohol and with liver disease benzodiazepines, are used (Zador et

al., 1996) with respiratory disease in late pregnancy who are breastfeeding PRESCRIBING BENZODIAZEPINES Drug Interactions Refer to Table 11–1. Rational Use of Benzodiazepines Use in Management of The following guidelines (RACGP, 2000) are Anxiety and Insomnia recommended when prescribing benzo- Benzodiazepines are effective for relief of diazepines: anxiety symptoms and will induce sleep if given in sufficient doses (Therapeutic Guide-

avoid prescribing benzodiazepines to lines Ltd., 2000). Research has questioned people suspected of using other the efficacy of prescribing benzodiazepines psychoactive drugs for symptom reduction in anxiety manage- advise all patients prescribed benzo- ment, with studies demonstrating that coun- diazepines of the risk of dependence selling alone has similar, if not greater effi- to prevent inadvertent dependence, en- cacy (Catalan et al., 1984). courage patients to see the same doctor for repeat prescriptions Benzodiazepines have demonstrated efficacy prescribe benzodiazepines in the lowest in the short-term management of insomnia, possible dose for the shortest possible time however similar results have not been dem- reduce benzodiazepine dose only with the onstrated for periods longer than two weeks patient’s consent and cooperation (NHMRC, 1991). Insomnia should be regarded rely on non-pharmacological approaches as a symptom requiring assessment and to manage anxiety and insomnia evaluation, rather than a diagnosis per se. A before writing a repeat prescription for sleep–wake history may reveal the patient benzodiazepines, undertake a review of to: all medications (and ask about visits to be functioning normally on the amount of other general practitioners) sleep obtained

150 Chapter 11

have unrealistic expectations of the re- MANAGEMENT AND quirements for sleep INTERVENTION STRATEGIES have a disorder of the sleep–wake schedule (including problems associated with shift work) which is not improved with Reviewing Benzodiazepines hypnotics in Long-term Users: have a specific sleep disorder such as A Staged Approach sleep apnoea or narcolepsy, in which advise the patient you want to review their case hypnotics are contraindicated benzodiazepine medication with them assess dosage and pattern of use Finally, many patients who have taken assess use of alcohol and other

benzodiazepines for periods in excess of 4–6 Benzodiazepines psychotropics months have unwittingly become, dependent and experience withdrawal insomnia (Busto assess withdrawal symptoms et al., 1986; Therapeutic Guidelines Ltd., 2000). assess reported and observed side effects

Table 11–1 Drug interactions

Interacting drug Mechanism of Clinical effect interaction

Alcohol or other additive effect increased sedation CNS depressants

Antacids, decreased delayed onset of acute clinical anticholinergics absorption effects of benzodiazepines

Oral contraceptives, reduction in prolongation of elimination half- isoniazid metabolism life and effect of benzodiazepine

Cimetidine inhibition of increased toxic effects due to metabolism elevated plasma concentrations of diazepam

Rifampicin increased elimination half-life of metabolism benzodiazepine shortened

Digoxin protein binding increased digoxin levels diazepam altered

L-dopa unknown exacerbation of parkinsonian symptoms

Disulfiram decreased increased effects of metabolism benzodiazepine

Source: Norman et al. (no date, p. 37)

151 assess history of depression fatigue assess other medical problems (e.g. pain) tinnitus discuss long-term use with the patient hyperacusis, photophobia, perceptual discuss withdrawal symptoms with the disturbances patient depersonalisation, derealisation finalise the management plan blurred vision

(Mant & Walsh, 1997; NPS News, 1999) Principles when helping the patient withdraw from benzodiazepines Dependence and Withdrawal withdrawal must be gradual (e.g. 10–20% per week, slowing reduction at lower doses Benzodiazepines tolerance and withdrawal from e.g. < 15 mg diazepam) benzodiazepines can occur in individuals a reducing regime will generally take 6–8 who have been taking therapeutic doses weeks (or longer especially with higher of benzodiazepines for two or more weeks doses) it is estimated that symptoms may occur make a contract with the patient in up to 45% of patients discontinuing low therapeutic doses and up to 100% of pa- gradually reduce the patient’s dose us- tients for high doses ing a set reducing dosage over a set time period (e.g. reduce the most important there is a significant risk of withdrawal if dose of the day by ¼ of the tablet) benzodiazepines are discontinued abruptly, particularly in the sick and elderly. consider converting the patient to a benzodiazepine with a long half life e.g di- Symptoms of withdrawal azepam, to reduce the severity of withdrawal symptoms (see benzodiazepine Commonly include: equivalence table below) insomnia anxiety Table 11–2 irritability Benzodiazepine equivalence table restlessness agitation depression 5 mg = 0.5–1 mg alprazolam diazepam tremor = 3–6 mg bromazepam

dizziness = 10 mg clobazepam = 0.5 mg clonazepam Less common but medically serious: = 1–2 mg flunitrazepam seizures (high dose ± alcohol) delirium = 1 mg lorazepam = 5–10 mg nitrazepam Other symptoms include: = 15–30 mg oxazepam

muscle twitching and pains = 10–20 mg temazepam anorexia, nausea = 0.25 mg triazolam metallic taste

152 Chapter 11

titrate the dosage reduction according to BENZODIAZEPINE MISUSE patient symptoms discuss sleep and stress management, Habitual Drug Users diet and exercise (‘Doctor Shoppers’) review regimen weekly provide support, reassurance and expla- Almost all GPs come across patients who may nation be obtaining prescriptions from several doctors. (NPS News, 1999) The following may help in responding effectively (Mant et al., 1997): Dose equivalents are approximate, some drugs at higher doses may be more potent.

do not prescribe a benzodiazepine on the Benzodiazepines first visit Aged Care there is rarely a valid indication for Residential Facilities benzodiazepines in young people Prescribing for residents in aged care facili- say ‘no’ from the start to the patient’s re- ties (and other residential facilities) presents quests for the prescription, whilst offering special difficulties. Accreditation of aged care your help as a doctor facilities has heightened awareness of respon- take the opportunity to discuss risks as- sibilities of the facility for quality use of medi- sociated with drug use and consider re- cines (Australian Pharmaceutical Advisory ferral to a specialist agency Committee, 1997). This responsibility includes drug utilisation review by an accredited pharmacist. The use of benzodiazepines is Drug Dependent Patients lower where staff have received education in The RACGP (2000) has endorsed the follow- geriatric care and where the organisational ing protocol for prescribing benzodiazepines culture is supportive (Roberts et al., 1998). in high doses on a regular basis the defini- tion of which is ‘more than three occasions Benefits for the elderly in aged care accom- per month for more than two months in any modation following successful reduction in one year.’ There are high risks with patients rates of benzodiazepine use include: seeking large quantities of benzodiazepines (and other drugs of dependence) from one increased mobility prescriber or from multiple prescribers. Most increased alertness high dose users cannot be managed with an reduced incontinence ordinary script. improved wellbeing (Gilbert et al., 1993) The protocol aims include the support of quality medical practice, reducing overdose deaths and indiscriminate prescribing to polydrug users while reducing barriers to doctors seeing drug-dependent patients.

A protocol for prescribing benzodiazepines in high doses on a regular basis (RACGP, 2000) follows.

153 Where relevant and appropriate the following should be undertaken and adequately documented in the medical record: a full history, including use of alcohol and other drugs and psychiatric comorbidity adequate physical examination problem/diagnosis list management plan, which should include the following: " consultation with another medical

Benzodiazepines practitioner with experience in management of drug dependence " communication with other prescribers, notably methadone prescriber " supply of specified small quantities (e.g. daily), whether at the surgery or, if applicable, at a community pharmacy. " communication with the Health Insur- ance Commission to clarify whether the patient is seeing multiple doctors for prescriptions for benzodiazepines and/or narcotic analgesics " monitoring of consumption where applicable by the Health Insurance Commission, with agreement by the patient to attend only one doctor and one pharmacy and signed consent to the doctor receiving feedback on actual consumption for the period of the contract

154 Chapter 11

REFERENCES

AIHW (Australian Institute of Health and Welfare) 2001, 2001 National Drug Strategy House- hold Survey: Detailed Findings, Drug Statistics Series no.11, AIHW Cat. no. PHE 41, AIHW, Canberra.

Ashton, H. 1991, ‘Protracted withdrawal syndromes from benzodiazepines’, Journal of Sub- stance Abuse Treatment, 8, pp. 19–28.

Australian Pharmaceutical Advisory Committee 1997. Integrated Best Practice for Medica- tion Management in Residential Aged Care Facilities, AGPS, Canberra. Benzodiazepines Busto, U., Sellers, E.M., Naranjo, C.A., Cappell, H., Sanchez-Craig, M. & Sykora, K. 1986, ‘Withdrawal reaction after long-term therapeutic use of benzodiazepines’, New England Journal of Medicine, 315, pp. 854–859.

Cape, G., Hulse, G., Robinson, G., Mclean, S., Saunders, J., Young, R. & Martin, J. 2002, ‘Sedative-hypnotics’ in Hulse, G.K. (ed.), White, J.J. & Cape, G., Management of Alcohol and Drug Problems, ch. 11, Oxford University Press, South Melbourne.

Catalan, J., Gath. D., Edmonds, G. & Ennis, J. 1984, ‘The effects of non-prescribing of anxiolytics in general practice — 1: controlled evaluation of psychiatric and social outcome’, British Journal of Psychiatry, 144, pp. 593–602.

Darke, S., Hall, W., Ross, M. & Wodak, A. 1992, ‘Benzodiazepine use and HIV risk-taking behaviour amongst injecting drug users’, Drug & Alcohol Dependence, 31, pp. 314–36.

Gilbert, A., Owen, N., Innes, J.M. & Sansom, L. 1993 ‘Trial of an intervention to reduce chronic benzodiazepine use amongst residents of aged-care accommodation’, Australian & New Zealand Journal of Medicine, 23, pp. 343–7.

Leipzig, R.M., Cumming, R.G. & Tinetti, M.E. 1999, ‘Drugs and falls in older people: a systematic review and meta-analysis. 1. Psychotropic drugs’, Journal of the American Geriatric Society, 47, pp. 30–39.

Mant, A., de Burgh, S., Yeo, G., Letton, T. & Shaw, J. 1997, Anxiety and Insomnia — Think Twice Before Prescribing, 3rd edn., RACGP (The Royal Australian College of General Practitioners), Melbourne.

Mant, A. & Walsh, R.A. 1997, ‘Reducing benzodiazepine use’, Drug and Alcohol Review, 16, pp. 77–84.

NHMRC (National Health and Medical Research Council) 1991, Guidelines for the Preven- tion and Management of Benzodiazepine Dependence, vol. 14, AGPS, Canberra.

Norman, T.R., Ellen, S.R. & Burrows, G. (no date), ‘Benzodiazepines in anxiety disorders: managing therapeutics and dependence’ MJA Practice Essentials, p.37, www.mja.com.au/ public/mentalhealth/articles/norman/norman.html.

155 NPS News 1999, National Prescribing Service Newsletter and Prescribing Practice Review, No 4 (July), National Prescribing Service Limited, Sydney.

Oster, G., Huse, D.M., Adams, S.F., Imbimbo, J. & Russell, M.W. 1990, ‘Benzodiazepine tranquilizers and the risk of accidental injury’. American Journal of Public Health, 80, pp. 1467–70.

PBS (Pharmaceutical Benefits Scheme) 1998, Australian Statistics on Medicines, Dept. of Health and Ageing, Canberra.

RACGP (Royal Australian College of General Practitioners) 2000, RACGP Guidelines for Rational Use of Benzodiazepines, Update October, RACGP, Melbourne,

Benzodiazepines www.racgp.org.au.

Roberts, M.S., King, M., Stokes, J.A., Lynne T.A., Bonner, C.J., McCarthy, S., Wilson, A., Glasziou, P. & Pugh, W.J. 1998 ‘Medication prescribing and administration in nursing homes’, Age and Ageing, May, 27, pp. 385–392.

Therapeutic Guidelines Ltd. 2000, Therapeutic Guidelines: Psychotropic 2000, Version 4, Therapeutic Guidelines Ltd., North Melbourne.

Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, 2nd edn., Custodial Medical Unit, Mornington, Victoria.

Zador, D., Sunjic, S. & Darke, S. 1996, ‘Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances’, Medical Journal of Australia, 164, pp. 204–7.

156 Other Drugs Chapter 12 HALLUCINOGENS T and psychiatric sequelae)rather thanregularordependentuse. and psychiatric effects fromacutedrug (especiallybehaviouralare likely toarise administeredorally, arenormally drugs onanirregularbasis. Harms isconsumed. for whichthedrug this isthemajorpurpose These cannabis, amphetamines),thelabel ‘hallucinogenic’ indicatesthat haveWhile arange ofdrugs potentialtoproducehallucinations(e.g. medicines is included in any drug usescreeningprogram.medicines isincludedinany drug andcomplementary thatuseofnon-prescription It isimportant used for ofcontexts. inavariety different purposes They include:

share a common pharmacology or pattern ofeffects andare orpattern share acommonpharmacology that areusedinnon-medicalcontexts. donot These drugs HERE over thecounterdrugs anabolic steroids ‘party drugs’ hallucinogens are somesubstancesnotcovered chapters inearlier 157

Other Drugs Other Drugs 158 dosed. Anticholinergicoverdose islife-threat- problematic, but canbeifthepersonhas over- tremor, hyperreflexia. These arenotusually pathomimetic effects includingtachycardia, consumed. LSDandpsilocybinproducesym- Other signsandsymptomsdependonthedrug referral.chiatric of theunpleasantepisodeandmay needpsy- ceased. dailyrecurrence Some patients report effectpletely subsidewhenthedrug has In isolatedcasesthesymptomsdonotcom- may berequired. tration ofabenzodiazepine (e.g. diazepam) important. Ifthisisnotsuccessful,adminis- A quiet,non-threateningenvironment is andcalmreassuretheperson. is totry control may beprominent. The bestresponse Agitation andfeelings ofpanicand lossof and Intervention Management This canresultfrom: ence. hallucinating, andisdisturbedby theexperi- mon presentationisapersonwhoactively icity. While theexact symptomsvary, acom- areduetoacutetox-most problems thatarise The irregularuseofhallucinogensmeansthat Psychological Effects Physical and The mostcommonhallucinogensinclude: dysphoric ratherthaneuphoric) dysphoric a ‘badtrip’(theexperiencehasbecome than thepersonisaccustomedto);or an overdose(thestrengthofeffectisgreater plant sourcese.g. datura, angels’ trumpet) and anticholinergics (pharmaceuticals and otheractive compounds) magic mushrooms(containingpsilocybin lysergic aciddiethylamide (LSDoracid) or ‘ Party drugs Party PARTY DRUGS Party drugs (sometimesknown as drugs Party ‘ Other drugsusedaspartyinclude: Handbook. chaptersinthis been discussedinearlier amphetaminesandecstasy, drugs, party have clubs orsimilarsituations. Two ofthemain stances taken inthecontext of ‘raves’, night- tion, overdoseandotherharms. This practiceincreasestheriskofintoxica- includingalcohol. bination withotherdrugs, used, but treatmentisusuallyconservative. hours andeven days. Physostigmine hasbeen ening andtheeffectsmaypersistformany dance drugs dance ketamine GHB (gammahydroxybutyrate) LSD (seeabove) ‘Polydrug Use’,p.5 Overview andIntroduction See Chapter1 Amphetamines; Ecstasy See Chapters6&7 is a term used to describe sub- usedtodescribe isaterm ’) arefrequentlytaken incom- club drugs club ’ verse effectsusuallysubsidewithin12hours. and metabolism.Itiseasytooverdose.Ad- is wideinterpersonalvariationintolerance consequent narrowtherapeutic index. There and GHB hasasteepdoseresponsecurve Unpleasant sideeffects may include: Common effectsinclude: plasma concentrationsin20–60minutes. GHB isabsorbedrapidlyandreachespeak effects Physical and iseasytomanufacture. was initiallydeveloped asahypnotic agent acid(GABA).aminobutyric Asyntheticform similartogamma cells andisstructurally GHB occursnaturallyinsomemammalian Street namesinclude: taken ofasolution. intheform andfairly tastelesspowder usually odourless Gamma hydroxybutyrate(GHB)isaclear, GHB method forassessingGHBuse. body fluids.Takinganoralhistoryisthebest assessment GHB isverydifficulttodetectormeasurein and Detection vomiting nausea dizziness drowsiness pleasant disinhibition mild euphoria placidity GBH (grievous bodilyharm) fantasy liquid ecstasy Chapter 12 McDowell (1999). byagement ofGHBintoxication, asdescribed Table 12–1outlines thefeatures oftheman- notably alcohol. Itmay presentas: when itistaken withothersubstances, most Most fatalities associatedwithGHBoccur within15–20minutes ofingestion. curring GHB overdose isarealdanger, usuallyoc- tion shouldbeprovided. treatment ensuringadequaterespiratoryfunc- intervention In mildercasesofintoxication,supportive and Management tive tosetting. is difficultandtheeffectsare highlysensi- tion (1–2hours)ofaction.Dosage titration Ketamine hasarapidonsetbutshortdura- effects Physical be injectedortakenorally. Ketamine isusuallysnortedbutmayalso Its streetnamesinclude: as ‘ecstasy’. as ketamine orasaconstituentofpillssold users. drug amongst party Itmay besold tagonist. Ithasrecentlybecomepopular (NMDA)n-methyl-d receptoran- aspartate Ketamine isadissociative anaestheticand Ketamine coma depression respiratory aggressive outbursts seizures nausea andvomiting special K vitamin K super K K 159

Other Drugs Other Drugs 160 Management ofGHBintoxication Table 12–1 Adverse effects caninclude: Ketamine cancause: care unit. should be managed in an intensive Patients whose breathing is laboured Dischargeor she he thepatient if 6. heor sheis the patient Admit if 5. Use atropine for persistent 4. Attempt to keep the patient 3. Maintain comprehensive 2. Maintain oxygen supplementation 1. For spontaneously breathing patients: agitation anxiety stimulant effects perceptual distortion(psychedeliceffects) aphrodisiac effects,hallucinationsandother outofbodyexperiences, thought disorders, is clinically well in 6hours intoxicatedstill hours after6 symptomatic bradycardia stimulated monitoring physiological and cardiac and intravenous access individuals (McDowell, 1999,p. 301). Ketamine cancreatedependencyinsome women usethesedrugs. nated by malesbut agrowing number of shape. Anabolicsteroiduseiscurrentlydomi- used for cosmeticreasonstomodifybody performance but arenow widely ing sporting ally, they have beenassociatedwithenhanc- testosterone.the malesex hormone Tradition- Anabolic steroidsaresyntheticvariationsof ANABOLIC STEROIDS should becloselymonitored. should beprovided. Levels ofpatientanxiety environment withlow lightingandstimulation require symptomaticreliefandobservation. An intervention lived and Most clinicalpresentationsareshort and Management coma injury ofaccidental thereby creatingahighrisk dissociation analgesia andsensory paralysis temporary hypertension chest pain tachycardia with alcohol) nausea andvomiting(especiallyiftaken ‘bad trips’(knownasthe‘Khole’) medication groupscancauseconcern: psychoactive effects. inthefollowing Drugs A number have ofover thecounterdrugs OVER THE COUNTERDRUGS and kidneys. involving thecardiovascular system,liver to potentiallylife threateningcomplications as acne, lowering of thevoice andbaldness from relatively minor cosmeticchangessuch ciated withanabolicsteroids. These range A vastarrayofsideeffectshavebeenasso- or otherdrugsaretakenatthesametime. ‘stacks’, thatis, anumberofanabolicsteroids Anabolic steroidsarecommonlyusedin small numberofpeopleusingcontinuously. but anaveragewouldbe6to8weekswitha nence. Thelengthofacyclecanvarywidely period ofusefollowedbyaabsti- muscular injection,generallyincycleswitha They areprimarilytakenorallyorbyintra- Concern forcodeine-containingproducts: codeine Paracetamol, Analgesics for inthefollowing concern medicationgroups: indicatecause by Stateauthorities) monitoring ticals. However anecdotalaccounts(andsome pharmaceu- tional misuseofnon-prescription Few dataareavailableontheextentofinten- Non-prescription Medication cough suppressants sympathomimetics antihistamines analgesics and saleasastreetdrug need tobeawareofthepotential forabuse make home-bakeheroin codeine isanopioidandcan beusedto Chapter 12 dextromethorphan, dihydrocodeine, Codeine, suppressants Cough phenylpropanolamine, Pseudoephedrine, Sympathomimetics dexchlorpheniramine, Chlorpheniramine, Antihistamines

pholcodeine phenylepherine promethazine pheniramine, diphenhydramine, hydrochloride, trimeprazine hydrochloride, histamines andmany otherdrugs often availableincombinationswithanti- and morerarelyarrhythmiasseizures overdose causestachycardia, palpitations, for useinpregnancy concern ture ofamphetamines high potentialfor diversion intomanufac- on stimulants potential for misuseby peopledependent athigherdoses tions, canoccur, particularly paradoxical stimulation,includinghallucina- sedation the combinationwithalcoholincreases tive effects use ofolderstyleantihistaminesfor seda- be avoided tion productsandrecommendationshould therapeutic justificationfor thesecombina- sics orsympathomimetics. There islittle used aloneorincombinationwithanalge- patic damagefromhighdoseparacetamol racetamol) increasethelikelihoodofhe- combination products(e.g.codeinepluspa- plus antihistamine succinate combinations,i.e.analgesic abuse ofparacetamol/codeine/doxylamine 161

Other Drugs Other Drugs 162 caps, ibuprofen/codeine gelcaps). soft gelatincaps(e.g.diphenhydraminegel cough andcoldmixtures)orpreparationsin requestsfor liquidpreparations(e.g. particular Dose formiscauseforextremecaution;in Injecting DrugUsers uncommon. medicinesarenot drops andcomplementary of awiderangeproductsincludingeye ofexperimentation withuse Anecdotal reports Other Psychiatric Press, Psychiatric Washington D.C., p. 301. M. &Kleber, H.D. (Eds.) 1999, McDowell, D.M. 1999, ‘MDMA, Ketamine, GHBandthe “Club Drug” Scene’,citedinGalanter, REFERENCES Chapter 12 Textbook of Substance Abuse Treatment Abuse Substance of Textbook , 2 nd Edn., American Chapter 15 163

Other Drugs Other Drugs 164 Part 3

Non-medical Interventions

165 166 Interventions Psychosocial Chapter 13 This Chapterbrieflycoversthefollowingclinicalstrategies: interventions thatareconsistentacrossalloftheseapproaches. outlined below.However,therearekeyfeaturesofpsychosocial T

quality oflife relapse prevention goal setting problem solving motivational interviewing building atherapeuticalliance decision balance patient centredapproaches drug use.Anumberofdifferentmodelsandapproachesare social interventionsinaddressingproblematicalcoholand HERE is astrongevidencebasefortheefficacyofpsycho- 167

Psychosocial Interventions Psychosocial Interventions 168 rigid categorisationsofpatients. focus ofinterventions.Cliniciansshouldusethemodelwithcaution,avoidingsimplisticand process. Whileempiricalsupportforthismodelislimitedthecanstillhelpstructure effort. ProchaskaandDiClemente(1986)developedausefulfive-stagecyclicalmodelofthe without suchhelp.Havingsomeunderstandingoftheprocesschangecanguideclinical People dogiveupharmfuldruguse,sometimesassistedbyformalinterventions,othertimes A MODELOFTHEPROCESSCHANGE PATIENT READINESS— tinuing Pre-contemplation theprosofcon- During Pre-contemplation Stage accept thisascollateraldamage. patient’s druguse,butthepatientmay concerned aboutsomeconsequenceofyour outweigh advantages.Youmaybe drug use.Disadvantagesofchange Source: ProchaskaandDiClemente(1986) Model oftheprocesschange Figure 13–1 PRE use - CONTEMPLATION outweigh theconsofcontinued ( CONTEM A e.g. smoking) e.g. bvln about mbivalent RELAPSE PL (progess usuallyoccursinaclockwisedirection) A TION overdose. be keentogetadviceon how toavoid to managesleepdisorders. Aheroinusermay borne virusesorhow about howtoavoidblood ing amphetaminesmightwelcome information be well received. For example, apersoninject- andhowrisks, toavoid orminimisethem,may how to ‘give up’,but relevant about information interventions’oriented andexplanations about Commonly, thereisresistanceto‘action MAINTENANCE ( ACTION Motivated to Motivated make change) make ( EXIT long success) - term support changecanhelp. support andidentifyingstrategies to ports/resources sup- andexternal setting, identifyinginternal worthwhile. This is oftenaplanningstage. Goal their capacitytochange. Changeisseenas totake actionandhasconfidencein paring The balancehasshifted. The patientispre- Preparation Stage interviewing. Explore thisambivalence usingmotivational although thereisstillambivalence aboutchange. The balanceofcostsandbenefitsbegintoshift, Contemplation Stage use. ofdrug disadvantages ofcurrentpatterns help thepatientexploreadvantagesand Use motivationalinterviewing(seep.172)to maintaining changetoreinforce theirdecisions. thepositive reasonsfor patients toarticulate itandrelapseismorelikely.worth Encourage tochangemay notseem changes, theeffort physical andmentalwellbeing). Without such (e.g. housing,employment, relationships, substantial improvements inthequalityoflife months ormoreareusuallyassociatedwith Changes inbehaviour maintainedfor six Maintenance Stage to change. Review initialreasonsthatledtothedecision and specificskilltrainingcanbeprovided. The patientistakingstepstochange. Support Action Stage ‘I should give up because of all the prob- the all of because up give should ‘I lems. But what am I going to do instead? do to going I am what But lems. — I’ll miss it and my friends.’ my and it miss I’ll — Chapter 13 judged. being municate concernswithoutfearof based ontrust,wherethepatientcancom- come. Itisimportanttobuildarelationship, fied, clinicianscansignificantlyinfluenceout- Even whenatreatmentisdeliveredasspeci- Therapeutic Alliance Building A conclusion. theprocesstoapremature ing orhurrying the patient’s selfre-evaluation withoutjudg- professional’s roleistolistenandreflectback and disadvantages ofchange. The health they nolongeruse. Considertheadvantages when to thinkaheadanimaginedscenario current situationasasubstanceuser. Then sider advantages anddisadvantages oftheir Exercise: The patientisasked tofirstcon- by thepatientathome. theconsultationorcompleted either during and consofsubstanceuse. Itcanbeused change. Itcanhelppeoplere-assessthepros understand thefirsttwoingredients of The DecisionBalancecanhelpyou tobetter Decision Balance Table 13–1. The patient-centredapproachisoutlinedin Patient-centred Approach and maximiseprobabilityofbehaviourchange. provided lationship, enhancequalityofsupport strategies canfacilitate agoodtherapeutic re- The followingsetofempiricallytestedclinical CLINICAL STRATEGIES See AppendixJ 169

Psychosocial Interventions Psychosocial Interventions 170 Patient-centred approach Table 13–1 clinical practice that: tention andtreatmentoutcomeresultfrom Improved treatmentadherence,re- is non-judgmentalandgenuine method andtreatmentgoal facilitates choiceoftreatment informed communicates confidenceandoptimism is empathetic substance use substance re-evaluate their Help patients and confrontation Avoid argumentation for them to quit i.e. how important it is problem they have, how much of a Let the person decide discrepancy Encourage personal choice behaviour as their Regard the person’s • • • • • change: Three ingredients are necessary for any behaviour • • • • • • •

belief that change is possible (self-efficacy) belief that change will lead to improvement use examples and issues raised by the patient use the Decision Balance to identify discrepancies concern with current behaviour separate would increase this score. If the score is high, why? confidencewhatexplorelow,10.isIf score outof encourage the patient torate their motivation and (dislikes) as perceived by the patient systematically explore benefits (likes)and costs choices enhances their autonomy and responsibility understanding and acknowledgingthepatient’s confrontation in conflict with personal goals change is likely tooccur when behaviour is seen to be acknowledge benefits as well as costs to behaviour information better understand,andtohelpdevise action This istohelpboththepatientandclinician listening Empathy involves: reflective and Empathy within is trying tocommunicate is trying captures theessenceofwhatpatient responsethat patient —formulate a brief communicating thisunderstandingtothe cerns understanding thepatientandtheircon- listening tothepatient the patient is the goal from ‘ from persuasive imperative persuasive ’ Reflective listeningcan include: rather than toodefinitive. tobetentative of meaning,itisimportant (verbal orotherwise)canhave several levels correction). Because many communications to usesimplereflective questions(i.e. invite figure.thority Inthiscaseitmightbeuseful be reluctanttocorrectastatementby anau- times apatient(e.g. ayoung person)could ment ratherthanaquestion. However, some- Some reflective listening ismadeasastate- also away tofeed back thepatient’s concerns. derstanding andaddmoreinformation. Itis It allows thepatienttocorrectany wrongun- what you ‘heard’ iswhatthepatientintended. Reflective listeningisaway tocheck whether listening Reflective Instead, askopenquestionssuchas: Avoid questionssuchas: tion by thepatient. factual but information, discourageexplora- questions Closed questionsmay beusefulfor getting ended open Using involves several micro-skillsincluding: Listening andcommunicatingunderstanding experience ofdruguseandrelatedharm. are seekingtounderstandthepatient’sunique 1994).You based onthisunderstanding(Egan, ‘How has your injecting changed over time?’ over changed injecting your has ‘How now?’ often more inject you ‘Do ‘You don’t see why your amphetamine use amphetamine your why see don’t ‘You simple reflectionback tothepatient: is a problem when your friends use more use friends your when problem a is ‘What can you tell me about your injecting?’ your about me tell you can ‘What than you and they don’t seem to have any have to seem don’t they and you than problems.’ Chapter 13 These include: that canpreventempathy(Jarvisetal.,1995). empathy There areanumber ofcommon ‘roadblocks’ to Roadblocks can involve theabilityto: information.stand andsummarise This skill An effective cliniciancanattendto, under- Summarising

‘I can see how this might be confusing. On confusing. be might this how see can ‘I problems, any have don’t friends your if ‘So giving adviceorproviding solutions orlabelling ridiculing moralising arguing orpersuading orthreatening warning orcommanding ordering the same) highlight ambivalence (to changeorstay orreasonsforown change concerns toheartheir give patientstheopportunity encourage exploration ofmoredetail highlight maindiscoveries castic way): amplifying orexaggerating (notinasar- other sideofthepatient’s ambivalence by amplified reflectionattemptstoelicitthe double sidedreflection: a strategy. youClearly needtobecautioususingsuch the one hand you’re here because you because here you’re hand one the about.’ worry to you for nothing there’s have some concerns about your ampheta- your about concerns some have mine use. On the other hand, you don’t you hand, other the On use. mine seem to be using more than your friends.’ your than more using be to seem 171

Psychosocial Interventions Psychosocial Interventions 172 ing (Miller&Rollnick,1991): interviewing Motivational involves interviewing thefollow- motivational of Elements help patientsexplore withambivalence and as amethodtowork hasbeenproposed Motivational interviewing cessful, oftengeneratingmoreresistance. some confrontpatients, onlytofinditunsuc- perplexes manyharm clinicians. Asaresult, use. This attachmenttobehaviours thatcause Many patientsarestronglyattachedtodrug Motivational Interviewing It isalsoimportanttoavoid: drug use. drug ‘How do you see the connection between connection the see you do ‘How heroin, using like ‘I discrepancy: Focus thepatient’sattentionon develop discrepancy listening andless‘telling’. Motivational interviewingconsistsofmore express empathy collusion using jargon clichés repetition insincerity This canincluderaisingawareness: your smoking and your poor respiratory poor your and smoking your with my family and the police.’ the and family my with health?’ more detailoftheseskills. etal.See Jarvis (1995)for their but but reasonstochange I hate the hassles the hate I

interviewing In motivationalyou: interviewing motivational for Guidelines persist with efforts tochange. persist withefforts influence whetherornotthey attemptand plement andsustainchangedbehaviour will The patient’sconfidenceintheirabilitytoim- ‘What are the things you like and don’t like don’t and like you things the are ‘What " Try roll withresistance couraged toargueforchange. The avoid argumentation other perspectives.Forexample: Help thepatientconsiderissuesfrom that youaretakingawrongapproach. patient resists,thismaybeanindication (sometimes withtheclinician’shelp).If portunity forthepatienttoidentifysolutions elicit self-motivational statements: standing understand andcommunicateunder- to use reflective listeningandsummaries specific concerns toexplore thepatient’sprovide opportunity use quences ofdrug explore positive andnegative conse- " support self-efficacy about your cannabis use?’ cannabis your about ‘What have other people said about your about said people other have ‘What drinking?’ ‘What makes you think you might need to need might you think you makes ‘What cal findings ask thepatienttheirviewofyourclini- of asignificantothermightbeetc. ask thepatientwhattheythinkview not change?’ patient toprovidesolutions.Provideop- , andnottheclinician,isen- tient areconfrontingtheproblem(s) together. ing thepatient. Itshouldfeel you andthepa- It shouldnever feel asthoughyou areconfront- Avoid: following seven components: motivationalconsistsofthe interviewing Brief and clinicallyuseful: (Rollnick etal.,1999). Two factors arecentral arewellresearched istic interventions andopportun- motivational interviewing Brief Interviewing Brief Motivational then usethisinformation: on. areas towork the mostimportant You can You canusescaling tohelpquickly identify Ask questionssuchas: questions Scaling ‘Why is it so high?’ high?’ so it is ‘Why for it is important how 0–5 of scale a ‘On tation tobreakdown denialwithconfron- trying telling themwhattheymustdo imposing adiagnosticlabelonthem arguing withapatient ‘ can change,butitisnotimportanttothem confidence —e.g. someareconfidentthey they candoit tant toquitsmokingbut are notclearhow —e.g.importance somethinkitisimpor- ‘ change: help thepatientdecidewhetherto What doesthismeanforyourdruguse Where doesthisleaveyounow it a zero? a it you to give up smoking?’ up give to you ‘On a scale of 0–5 how confident are you are confident how 0–5 of scale a ‘On about giving up?’ giving about ’) (Even ifa‘1’ Chapter 13 ‘Why isn’t ‘Why ?’ ?’ tise isimportant. How you andyour shareinformation exper- information Exchanging confidence Building Summarise importance Exploring ‘What are the benefits of your cannabis use?’ cannabis your of benefits the are ‘What level?’ this at you keep help will ‘What ‘How much do you already know about the about know already you do much ‘How when helpful been has what past, the ‘In now?’ you leave that does ‘Where risks of injecting?’ of risks you have tried to change your drug use?’ drug your change to tried have you ‘What are some of the less good things?’ good less the of some are ‘What higher?’ move you help will ‘What ‘Some people find that …how about you?’ about …how that find people ‘Some these from learn can you anything there ‘Is ‘How high does it have to be before you before be to have it does high ‘How past attempts?’ past ‘How do you see the connection between connection the see you do ‘How make an attempt to change?’ to attempt an make ‘Is there anything you can learn from other from learn can you anything there ‘Is your amphetamine use and your sleep- your and use amphetamine your ‘What can I do to help?’ to do I can ‘What ing problems?’ ing people’s attempts to change?’ to attempts people’s ‘Is there anything more you’d like to know to like you’d more anything there ‘Is about injecting?’ about 173

Psychosocial Interventions Psychosocial Interventions 174 a decisiontochange. 2. Define the problem — problem the Define 2. Orientation 1. that canbelearned: Effective problem solvingconsistsoffive steps they took. solved otherproblems andnotingthesteps of identifyingoccasionswhenthepatienthas Developing problem solvingskillscanconsist best achieved through: solving skillscanbeclinicallyusefulandis come. development Supporting ofproblem is associatedwithimproved treatmentout- The abilitytorespondeffectively toproblems Problem Solving (Based onMason,1997). action invite and Summarise onus isthenonthepatient, tient tocollaborateinproviding asolution. The toprovide solutions—invite thepa- Don’t try Emphasise personalchoiceandcontrol. culty ofchanging. Express empathy, especiallyaboutthediffi- resistance Reducing ‘What do you think you should do about do should you think you do ‘What learning throughpracticeandfeedbacklearning demonstration (whenpossible) formation in- a combinationofverbal andwritten someone elsesolve this? challenge, notacatastrophe. How might Stand back fromtheproblem; view itasa it is important to be specific be to important is it your cannabis use?’ cannabis your ain:‘ Patient: My wife and I do not get on get not do I and wife My not you not , tomake ’ 4. Decision making Decision 4. solutions Brainstorm 3. Effective goalsettingis: Goal Setting she canuseinavariety ofcircumstances. tient’s problems, but toteachaskillthatheor It isnotyour responsibilityto solve thepa- Implementation 5. to embrace. an informed choiceofthebestoption(s) their abilitytoimplementthem,andmakes and negatives ofeach oftheoptions, and tion, oftheclinician)reviews thepositives The patient(withthehelp, but notdirec- evaluation andasearchfor quality. many solutionsaspossible —discourage At thisstage,anything goes. Identifyas component parts tic goalmay bebroken down into several specific andachievable. Abroadtherapeu- realistic herence to generatepatientcommitmentandad- haviour. Negotiatedgoalsaremorelikely a patient. Itisastrategy toinfluencebe- negotiated. Negotiationisnotbestowed on ofinfection)embrace reducingtherisk sist agoaloftotalabstinence, but may change’ (e.g. a ‘pre-contemplator’ may re- consistent withthepatient’s ‘stage of crease self-efficacy(confidence). out theviabilityofstrategy andtoin- rehearse theoption(wherepossible) totest is implemented.Sometimesitusefulto A planofactionisdeveloped andtheoption ain:‘ Patient: lnca:‘ Clinician: She doesn’t like me being out being me like doesn’t She what of example an me Give on Friday nights Friday on mean you ’ ’ ing andmanagingrelapse: The following strategiesareusefulinprevent- and theabsenceofcopingskills. disease models(‘ arebeliefsystems consistentwith relapse risk evidence indicatesthatmajorpredictorsof usingbehaviour.changing drug Research when Relapse isacommonexperience Relapse Prevention relapse drill ofa develop strategiesthatcanbepart harm) useanddrug-related ofdrug monitoring social skills;self-managementself- teach copingskills(e.g. problem solving; in thepast?) tions have beenassociatedwithrelapse does thepatientuseheavily? What situa- identify high-risksituations(e.g.When motivational interviewing) enhance commitmenttochange(e.g. use drinking days)drinking as opposedtodecreasingthenumberof number ofdays withoutheavy alcoholuse ence, notabsence(e.g. increasingthe acquisition, rather thanreduction; pres- of successful ifcouchedinpositive terms terms. Changingbehaviour willbemore solution-focused, ordefinedinpositive tored andsuccessquickly realised short-term; sothatprogresscanbemoni- " " " " practice? an appointmenttocomebackyour How soonshouldthepatientmake what rolecanfriends/familyprovide? where cantheygetsupport? of alapseoccurring? what shouldthepatientdoinevent I’m an addict and can’t stop can’t and addict an I’m Chapter 13 ’), These mightinclude, but arenotlimitedto: services. a rangeofadviceandsupport tors, but you may beable tofacilitate accessto cannot beexpected toaddressallthesefac- defined). (variously support and spiritual You ity ofrelationships,financialsecurity, housing ated withfactors suchasemployment, thequal- Successful maintenanceofchangeisassoci- Quality ofLife

employment, educationandtraining legal advice services financial support housing services 175

Psychosocial Interventions Psychosocial Interventions 176 Mason, P. 1997, Jarvis, T.R.,Tebbutt,J.&MattickR.P.1995, Egan, G.1994, REFERENCES Rollnick, S.Mason,P.&Butler,C.1999, Miller, W.R. &Rollnick, S. 1991, Prochaska, J.O.&DiClemente,C.C.1986,‘Towardacomprehensivemodelofchange’in Cole, California. Churchill Livingstone, Edinburgh. Plenum Press,NewYork,pp.3–27. Education and Training onAddiction,FlindersUniversity ofSouthAustralia, Adelaide. Miller, W.R.,Heather,N.(eds.) Addictive Behavior Addictive Dependence. An Introductory Guide Introductory An Dependence. The Skilled Helper: a Systematic Approach for Effective Helping Effective for Approach Systematic a Helper: Skilled The Training People to Use Motivational Interviewing Skills Interviewing Motivational Use to People Training , Guilford Press, New York. Motivational Interviewing: Preparing People to Change to People Preparing Interviewing: Motivational Treating Addictive Behaviors: Processes of Change of Processes Behaviors: Addictive Treating Health Behaviour Change: a Guide for Practitioners for Guide a Change: Behaviour Health , John Wiley &SonsLtd.,Chichester, England. Treatment Approaches for Alcohol and Drug and Alcohol for Approaches Treatment , NationalCentrefor , Brooks/ , , Therapies Alternative Chapter 14 the treatmentofsubstanceuseareacupunctureandh therapies thathaveThe alternative beenmostcommonly appliedto T therapies. Assessingeffectiveness ismadedifficultby the: There arevariable levels ofevidence inregardtoalternative EVIDENCE OFEFFECTIVENESS

interventions andoutcomemeasures interventions considerable heterogeneityinparticipants small sizes ofstudies controlledstudies) small numberofstudies(particularly music therapy chiropractic hypnosis faith healing traditional orientalmedicine therapeutic massage homeopathy herbs acupuncture therapeutic practices, including: non-orthodox medicine’alternative isappliedtoadiverse collectionof HE TERM ‘alternative therapies’or‘complementaryand ‘alternative ypnotherapy. 177

Alternative Therapies Perhaps in part because of these factors, or to existing treatments in: results of studies are frequently contradictory

(Linde et al., 2001). the detoxification primary rehabilitation Acupuncture relapse prevention of opioid or cocaine dependence Acupuncture is a family of procedures involving stimulation of anatomical locations on the Conversely there is very little evidence that skin by a variety of techniques (Smith et al., acupuncture is not effective in the treatment 1997). The most studied form employs of these conditions (McLellan et al., 1993). penetration of the skin by thin, solid, metallic needles, which are manipulated manually or by electrical stimulation. Acupuncture points Two subsequent randomised controlled trials may also be stimulated by pressure, heat, and have also failed to identify either benefits or lasers (NIH, 1997). harms from acupuncture as an adjunct treatment for cocaine users (Bullock et al., 1999; Otto et al., 1998) or alcohol dependent out- For the treatment of substance abuse, five patients (Sapir-Weise et al., 1999). points on the ear are most commonly used (McLellan et al., 1993). However, in a randomised controlled trial

Therapies Avants et al. (2000) compared acupuncture

Alternative Most research into the effectiveness of acu- to a relaxation control and a needle-inser- puncture relates to smoking cessation. In a tion control for the treatment of cocaine-de- systematic review of 18 studies of acupunc- pendent methadone-maintained patients. ture for smoking cessation White et al. (2000) The trial found that the acupuncture group concluded that there is no clear evidence that was more likely to provide cocaine-negative acupuncture is effective for smoking cessa- urine samples than either of the two control tion. This review looked at abstinence from groups. These researchers went to some ef- smoking both early (up to 6 weeks) and late fort to identify sham acupuncture sites with (6 to 12 months) after acupuncture treatment. sufficiently low level of activity to be used as a control, supporting the view that selection They found that: of sham sites may be a factor influencing outcomes (NIH, 1997); however, the benefit of acupuncture was not superior to sham acu- reduced cocaine use in the acupuncture puncture, or any other anti-smoking group was countered by significantly lower intervention, at any time point after treatment rates of retention in treatment — the mean

acupuncture did appear to be superior to survival time was 5.2±3.0 weeks for the acu- no intervention at the early follow-up, but puncture group, 6.7±2.5 weeks for the nee- this difference was not sustained dle-insertion control and 7.0±2.3 weeks for the relaxation control group. The US National Institute on Drug Abuse also concluded that there is no clear evidence that acupuncture is effective compared to placebo

178 other interventions ornotreatment. other interventions greater effect onsixmonthquitratesthanany were unable toshow thathypnotherapy hasa systematic review by Abbot etal. (2000)who cessation. This researchwas thesubject ofa ness ofhypnotherapy relatestosmoking Again mostoftheresearchintoeffective- (Stoil, 1989). more responsive toatreatmentapproach Hypnosis may alsohelp patientsbecome negative emotionalstates(Hall,1999). tomanage and inhelpingpatientstolearn the reductionofanxiety, relaxationtraining, a treatmentinitself. Aroleitmightplay isin treatment ofsubstanceuseproblems, andnot hypnosis isgenerally seenasanaidinthe them’soring (Temes, 1999). Itappearsthat the patienttoacceptsuggestionswithoutcen- would be ‘a stateofawareness thatpermits debate, but agenerally accepteddescription The exact definitionofhypnosis isamatterof Hypnosis (MacPherson etal.,2001; White etal.,2001). also occurredbut much lessfrequently vomiting, psychologicalandemotionalreactions tion ofsymptoms,fainting, nauseaand as themostcommonadverse effects. Aggrava- identified bleedingandpainattheneedlesite Acupuncture of Recent surveysofacupuncturepractitioners Effects Adverse (Richard etal.,1995). treatment willbebeneficialfor somepatients 1997). Indeed,itmay(NIH, bethat any adjunct ofacomprehensive managementprogram part approaches may beuseful for somepatientsas adverse effects arelow. Consequentlythese lematic substanceuse. However of therisks existing approachesinthetreatmentofprob- therapy arenomoreeffective thanplacebo or but suggeststhatacupuncture andhypno- Research evidence isscarceandconfounded, Conclusions Chapter 14 179

Alternative Therapies REFERENCES

Abbot, N.C., Stead, L.F., White, A.R., Barnes, J. & Ernst, E. 2000, Hypnotherapy for Smoking Cessation, Cochrane Library, Issue 2, Update Software, Oxford.

Avants, S.K., Margolin, A., Holford, T.R. & Kosten, T.R. 2000, ‘A randomized controlled trial of auricular acupuncture for cocaine dependence’, Archives of Internal Medicine, vol. 160, no. 15, pp. 2305–2312.

Bullock, M.L., Kiresuk, T.J., Pheley, A.M., Culliton, P.D. & Lenz, S.K. 1999, ‘Auricular acupuncture in the treatment of cocaine abuse. A study of efficacy and dosing’, Journal of Substance Abuse Treatment, vol. 16, no. 1, pp. 31–38.

Hall, H. 1999, ‘Hypnosis and pediatrics’, in Medical Hypnosis: An Introduction and Clinical Guide, Churchill Livingstone, Philadelphia, Pennsylvania, USA, pp. 79–93.

Linde, K., Vickers, A., Hondras, M., ter Riet, G., Thormahlen J., Berman, B. & Melchart, D. 2001, ‘Systematic reviews of complementary therapies—an annotated bibliography. Part I: Acupuncture’, BMC Complementary and Alternative Medicine, vol. 1, no. 3,

Therapies www.biomedcentral.com/1472–6882/1/3 Alternative McLellan, A.T., Grossman, D.S., Blaine, J.D. & Haverkos, H.W. 1993, ‘Acupuncture treatment for drug abuse: a technical review’, Journal of Substance Abuse Treatment, vol. 10, no. 6, pp. 569–576.

MacPherson, H., Thomas, K., Walters, S. & Fitter, M. 2001, ‘The York acupuncture safety study: prospective survey of 34,000 treatments by traditional acupuncturists’, British Medical Journal, vol. 323, pp. 486–487.

NIH (National Institutes of Health) 1997, ‘Acupuncture’, NIH Consensus Statement, vol. 15, no. 5, www.odp.od.nih.gov/consensus/cons/107/107_intro.htm

Otto, K.C., Quinn, C. & Sung, Y.F. 1998, ‘Auricular acupuncture as an adjunctive treatment for cocaine addiction. A pilot study’, American Journal on Addictions, vol. 7, no. 2, pp. 164–170.

Richard, A.J., Montoya, I.D., Nelson, R. and Spence, R.T. 1995, ‘Effectiveness of adjunct therapies in crack cocaine treatment’, Journal of Substance Abuse Treatment, vol. 12, no. 6, pp. 401–413.

Sapir-Weise, R., Berglund, M., Frank A. & Kristenson, H. 1999, ‘Acupuncture in alcoholism treatment: a randomized out-patient study’, Alcohol & Alcoholism, vol. 34, no. 4, pp. 629– 635.

Smith, M.O., Brewington, V., Culliton, P.D., Ng, L.K., Wen, H.L. & Lowinson, J.H. 1997, ‘Acupuncture’, in Lowinson, J.H., Ruiz, P., Millman, R.B. & Langrod, J.G. Williams, and Wilkins, Substance Abuse: A Comprehensive Textbook, Baltimore. pp. 484–492.

Stoil, M.J. 1989, ‘Problems in the evaluation of hypnosis in the treatment of alcoholism’, Journal of Substance Abuse Treatment, vol. 6, no. 1, pp. 31–35.

180 White, A.R.,Rampes,H.&Ernst,E.2000, White, A.,Hayhoe,S.,Hart,A.&Ernst,E.2001,‘Adverseeventsfollowingacupuncture: Temes, R.1999,‘WelcometoHypnosis’,in Library, Issue2.,UpdateSoftware, Oxford. prospective survey of32,000consultationswithdoctorsandphysiotherapists’, Medical Journal Medical Guide ChurchillLivingstone:Philadelphia,Pennsylvania,USA,pp.3–5. , vol. 323,pp. 485–486. Chapter 14 Acupuncture for Smoking Cessation, Smoking for Acupuncture Medical Hypnosis: An Introduction and Clinical and Introduction An Hypnosis: Medical Cochrane British 181

Alternative Therapies Therapies Alternative

182 Part 4

Issues for Special Consideration

183 184 and Pregnancy Drug Use Chapter 15 The goalsoftheassessmentprocessareto: ASSESSMENT D be undertaken and ongoingcaretobeinitiated. be undertaken peutic relationship. This willallow acomprehensive assessment to andfoster athera-non-judgemental approachwillbuild rapport As withallotheraspectsofhealthcareanempathic, isaneffectivedrugs way ofimproving pregnancyoutcome.

explore arange ofchoicesfor action pregnancy useduring drug provide factual abouttheeffects information ofalcoholand pregnancy assess thepossible impactofthesubstanceuseon establish whethersubstanceuseiscontinuing usefromthedateofwoman’sdrug period lastmenstrual thequantityandfrequencyofalcoholother determine intervention withwomenwhoarepregnantandusing intervention cause arangeofadverse effects. detectionand Early RUG and alcohol use during pregnancy isknown to and alcoholuseduring 185

Pregnancy Pregnancy 186 tions because of their drug oralcoholuse. tions becauseoftheirdrug termina- or arepressuredintoconsidering out aboutthepregnancy. Somefeel pressure damage they may have tofinding doneprior about are unexpected, women areconcerned and developing foetus. Asmany pregnancies useontheirpregnancy effects ofthedrug use aboutthe concerned Most womenarevery substance of impact the Assess inChapter13may behelpful. described Using aMotivational styleas Interviewing assessment. an whenundertaking change isnecessary to changeandherresourcesachieve An explorationofeachwoman’sreadiness age ofwomen thisisnotpossible because: use.other drug However for asmallpercent- is apowerful incentive toceaseallalcoholand is use ofpregnancy For mostwomenconfirmation substance whether Establish isavailableand alcoholhistory inChapter2. Detailed information onhow toobtainadrug skills asfor any otherhistory. Obtaining thisinformationrequiresthesame and quantity the Determine on the pregnancy the on continuing drug other and alcohol of frequency use from the date of the woman’s last woman’s the of date the from use menstrual period menstrual or benzodiazepines e.g.abruptly women dependentonheroin it may beinadvisable for themtostop they may notbeable tostopby themselves of continued use they may beunaware ofthepossible risks General Principles See Chapter2 Psychosocial Interventions See Chapter13 nance ornicotinereplacement therapy. safer suchasmethadonemainte- alternative useortransfertion orreductionofdrug toa istofacilitateThe goalofintervention cessa- isrecommended. ment services referral andalcoholtreat- tospecialistdrug options available. Consultationwithand/or individual’s resourcesandthetreatment available willdepend upon each The range ofsubstanceusetreatmentchoices comes for themotherandbaby. continued substanceusewillimprove out- Adequate pregnancycare, even intheface of care isapriority. pregnancy ismade, pregnancy(antenatal) use.their drug Ifadecisiontocontinuethe with thepregnancyortocontinue ormodify action for desirable, whetherthey decidetocontinue choices of A range of choicesfor pregnantwomen is range a Explore of actionfor theirindividualcircumstances. sist women indecidingwhatisthebestchoice Factual effects willas- aboutdrug information about information factual Provide the effects of substance use during use substance of effects the pregnancy stances, alcoholandtobaccothatarethe such asheroinandcocaineitisthelicitsub- Despite theattentiongiven toillicitsubstances et al.,1994). influence whatstudiesarepublished (Brady Finally thereistheissueofbiaswhichmay this research. These include: are multiple methodologicalchallengeswith complex andsometimescontradictory. There is tal exposure toalcoholandotherdrugs Research ontheextent andeffects ofprena- ofcontinueduse. risks andwithoutminimisingthepossible sarily womenunneces- formation withoutscaring explained. istoprovide balancedin- The art to becarefullyassessedandpossible risks Each woman’s individualexperience needs andaredependentonmultiple factors:vary The effectsofsubstanceuseduringpregnancy AND DRUG EFFECTS INFORMATION ONALCOHOL pregnancy used andthetimingofuseduring effects andboththeamountofsubstance therelationship between the determining substance difficulty inisolatingeffects ofa particular women samplesofpregnant finding appropriate amount andqualityofpregnancycare maternal nutritionandhealthstatus concurrent druguse,particularlytobacco timing anddurationofuse route ofadministration type andamountofsubstancesused Chapter 15 are relatedto: The effects ofalcoholexposure onthefoetus effects Foetal effects Prenatal adverse consequences. isthoughttobeunlikely tohavedrink any the infrequentconsumptionofonestandard pregnancyhowever alcoholduring drinking Women areadvisedtothinkcarefullyabout nancy), foetal andinfant effects. preg- hol inawiderangeofprenatal(during developing foetus. Researchimplicatesalco- women inAustralia anditcanbetoxic tothe mostcommonlyusedby Alcohol isthedrug Alcohol 1994). Foetal AlcoholSyndrome(Day &Richardson, a smalldecreaseincognitive functioningto These effects occuralongacontinuum from quences aremoresignificant. nancy andwhoseknown adverse conse- more commonlyusedbywomenduringpreg- the generalhealthofwoman the stageofpregnancy the amountofalcoholingested size andweight reduced birth premature birth andstillbirth (miscarriage) ofspontaneousabortion increased risk www.nhmrc.gov.au 187

Pregnancy Pregnancy 188 Holmes, 1997). thistime(Capus& metabolised during taken for 2to4hourssincethealcoholwillbe aslonganotherfeed isnotunder- harmful This level ofconsumptionisnotconsidered reduction strategyissuggested: lactationthefollowingalcohol during harm For womenwhodonotwishtostop using not recommended. therefore alcoholusewhilebreastfeeding is The infant’s brain issensitive toalcohol same asthewoman’s blood alcohollevel. The level ofalcoholinbreastmilkisthe breastfeeding and Alcohol ofdevelopingalcohol areatrisk withdrawal. towomenwhoaredependenton Infants born 1994). per weekormore(Jacobson &Jacobson, throughout pregnancyi.e. 42standarddrinks associated withchronicallyhighalcoholintake disability andthecranio-facial deformitiesare such asfoetal death,severe developmental Severe pregnancy effects ofalcoholuseduring (FAS) Syndrome The cardinalfeaturesofFASinclude: Alcohol Foetal after theinfant hasbeenfed andsettled nomorethanonestandarddrink drink minimal effect onbreastmilk consume alcoholattimeswhenitwillhave in someinstances andlimbdeformities together withheart anomaliesofthefaceing minorstructural defects includ- ofbirth a consistentpattern sulting indevelopment delay anddisability andfunctionre- anomalies ofbrain structure ing height,weight andheadcircumference slow involv- growth before andafterbirth effects Prenatal malformation rate(Woods&Raju,2001). likely tocauseanincreaseinthecongenital literature, smokingduringpregnancyisun- However basedonfindingsintheavailable compared withwomenwhodonotsmoke. nificantly smallerandofshortergestation during pregnancyhaveinfantsthataresig- gen supplytothefoetus.Womenwhosmoke stituents oftobaccosmokerestricttheoxy- Nicotine, carbonmonoxideandothercon- Tobacco general vicinity. after baby’s feed onlyandnotwithintheir infant. reductionmeasure, smoke Asaharm orwithinthevicinity ofafeedingduring to theinfant smokingisbestavoided to, prior ofpassive smokingexposureDue totherisk breastfeeding Tobacco usereducesthebreastmilksupply. and Smoking infections. infections,respiratory asthmaandmiddleear (Blair etal.,1996)andincreasedincidenceof small but significanteffect ofSIDS ontherisk effect. Parental misusehasanadditional drug hasanindependentadditive smoke afterbirth evidence thathouseholdexposure totobacco pregnancy. smokingduring ternal There isalso Death Syndrome(SIDS)associatedwithma- ofSuddenInfantThere isanincreasedrisk effects Infant effects Foetal increased risk ofprematurelabour increased risk ofmiscarriage increased risk premature birth of cigarettessmoked. tothenumber creases indirectproportion reduced foetal growth. de- Birthweight recommended. breastfeeding Breastfeeding whilstusingcannabisisnot and Cannabis (Hall &Solowij, 1998). cance ofthesefindingsareunclearatthistime insomestudiestheclinicalsignifi- reported and developmental have abnormalities been Although anumberofinfant neurobiological effects Infant effects Foetal cannabis (Hall&Solowij, 1998). current useoftobacco, for womenwhouse less compelling,andcompoundedby thecon- similar tothatoftobaccobut theevidence is The impactofcannabisuseonpregnancyis Cannabis possible increase in premature birth rate possible increasein prematurebirth reduced birthweight Chapter 15 of: risk Heroin usingwomenarealsoatincreased usingwomen. drug to womenmaintainedonmethadoneornon- thanthoseborn tend tobeoflower birthweight Babies borntowomendependentonheroin Heroin (Keen &Alison,2001). ent womencanimprove pregnancyoutcome Adequate pregnancycarefor heroindepend- et al.,1998). illicit substance(Ward etal.,1998,Kaltenbach statusofwomen dependentonan nutritional cific toheroinuseorthepoorhealthand It isunclearwhethertheseeffects arespe- uncertain, particularly behavioural problems, particularly uncertain, developmentalThe long-term outcomesare effects Infant effects Foetal effects Prenatal intra-uterine foetalintra-uterine death haemorrhage antepartum premature delivery increased incidenceofSIDS Neonatal AbstinenceSyndrome(NAS) hepatitis B&C, HIV infection: virus ofbloodborne increased risk premature birth foetal distress(meconiumstaining) headcircumference reduced birthweight, foetal ofintrauterine death increased risk increased rate ofbreechpresentation premature labour ofplacentalinsufficiency increased risk ofmiscarriage increased risk 189

Pregnancy Pregnancy 190 varies considerably duetoanumber offactors: The impactofpsychostimulantsonpregnancy Amphetamines andCocaine Psychostimulants — ment (Capus&Holmes,1997). using orarestabilisedonmethadonetreat- and discardtheirbreastmilkuntilthey stop breast feeding shouldbeadvisedtoexpress Women while whoareusingillicitdrugs bleeding nipples. vised tostopbreastfeeding if they develop Women whoarehepatitisCpositive aread- withdrawal symptoms. wean theirinfants of slowly toreducetherisk methadone (80mgormore)areadvisedto et al.,1998). Women onhigherdosesof methadone arepresentinbreastmilk(Ward methadone breastfeeding. Onlylow levels of any potentialdisadvantages ofwomen on breastfeeding The advantages ofbreastfeeding outweigh and Methadone cal supervision. ofpregnancyundermedi- second trimester the in methadonedosearepossible during access totreatmentservices. Slow reductions maintenance. Pregnantwomen have priority treatment who areheroindependentismethadone The treatmentofchoicefor pregnant women maintenance Methadone natal heroinexposure (Bradyetal.,1994). and parentingfactors notjustpre- afterbirth; as thesearerelatedtoenvironmental,social differences inmetabolism use ofdrug amount ofandpattern posure occurs ex- inwhich thedrug gestational period see Wardetal.(1998) For moredetailedinformation comes (Plessinger, 1998). ofadverse pregnancyout- increase therisk use ofpsychostimulants inpregnancywill ronmental andsocialstatus.Thecontinued genetic differences,polydruguse,andenvi- acting factors status, suchasnutritional Whether damageoccursdependsoninter- effects arenotallornothingphenomena. Malformations andlong-termbehavioural effects Prenatal the timeofwriting. ecstasy useonpregnancywas available at No conclusive ontheimpactof information Ecstasy effects Infant (Behnke etal.,2001). pregnancy psychostimulant useduring ofmalformation associatedwith pattern identify anincreasednumber orconsistent evaluation for congenitalanomaliesdidnot However alarge, prospective, systematic effects Foetal premature labour andhaemorrhage placental abruption hypertension maternal this time problems but inconclusive evidence at ofbehaviouralpossible increasedrisk formations ofcongenitalmal- possible increasedrisk headcircumference reduced birthweight, foetal distress(meconiumstaining) premature birth (Kaltenbach etal.,1998). of NAShasbeendifficulttoestablish methadonedoseandtheseverity maternal premature infants. The relationshipbetween require treatmentfor NASmore oftenthan tational ageoftheinfant. infants Fullterm on severity ofNASasdoesthesize andges- anaesthetics andanalgesiacanalsoimpact NAS. The typeoflabourandtheuse may exacerbate andprolongthecourseof Heavy pregnancy benzodiazepine useduring severity ofNASincluding: hours ofbirth. Many factors impactonthe ofsymptomsappearwithin72 The majority by signsandsymptomsof: NAS isageneraliseddisordercharacterised Neonatal AbstinenceSyndrome(NAS). methadone haveahighincidenceof Infants prenatallyexposedtoheroinor SYNDROME (NAS) NEONATAL ABSTINENCE ment isinstigatedwhenscores reacha Dr LorettaFinnegan. Pharmacotherapy treat- developed by originally modified scorechart Infants ofNASaremonitoredusing a atrisk Abstinence Syndrome Management ofNeonatal time oflastuse used;the natureanddosageofdrugs and sneezing, mottlingandfever vague autonomicsymptoms—yawning, ypnoea, chestrecession tach- distress—nasalflaring, respiratory vomiting anddiarrhoea yet uncoordinatedsucking, poorfeeding, gastrointestinal dysfunction—excessive andtremor irritability pattern, increased muscletone,disturbedsleep Central nervoussystemhyperirritability— Chapter 15 ning and ongoing monitoring ofthefamily.ning andongoingmonitoring must beinvolvedtion services inthecareplan- childprotec- abuse isidentifiedthestatutory and documented. ofneglect or Where risk is requiredandmanagementplansagreedto welfare professionals involved with thefamily meeting includingthefamily and allhealthand discharge fromhospital.Adischarge-planning totheir usingparentsisassessedprior drug to It isvitalthatthewellbeingofinfants born children (Keen &Alison,2001). ofneglectingorabusing their creased risk poor parenting. These parents areatin- many werevictims ofchildabuse and/orhad usingparents indicatethat Studies ofdrug CHILD PROTECTION patient lengthofstay (Oeietal.,2001). medication thusreducingseparationandin- outpatient cliniconcetheinfant isstable on can besuccessfullymanagedviaaspecialist be minimised. The ongoingtreatmentofNAS thetreatmentofNASshould and infant during not effectively managed. Separationofmother negative impactonmother–infant bondingif Neonatal AbstinenceSyndromecanhave a a settlingeffect (Capus&Holmes, 1997). tosuck, whichalsohas provide anopportunity for sleepinghasacalmingeffect. Dummies and theuseofswing cradles orhammocks to moderateNAS. Swaddling incottonsheets symptom relieftotheinfant mild experiencing Mothercraft techniquescanprovide significant used tomanageNASinAustralia. tered orallyisthemostcommonmedication An aqueoussolutionofmorphineadminis- of serioushealthconsequencesifnottreated. predetermined levelandtheinfantisatrisk 191

Pregnancy Pregnancy 192 Kaltenbach, K.,Berghella, V. &Finnegan,L. 1998, pregnancy: ‘Opioid dependenceduring Keen, J.&Alison,L.2001,‘Drugmisusingparents:Keypointsforhealthprofessionals.’, Oei, J., Feller, J. &Lui,K. 2001, ‘Coordinated outpatientcareofthenarcotic-dependentinfant.’, Ward, J.,Mattick,R.&Hall,W.1998, Behnke, M.,Eyler,F.,Garvan,C.&Wobie,K.2001,‘Thesearchforcongenitalmalformations REFERENCES Brady, J., Posner, M., Lang, C. & Rosati, M. 1994, ‘Risk and reality: Theimplicationsofprenatal Brady, J.,Posner,M.,Lang,C.&Rosati,M.1994,‘Riskandreality: Hall, W. &Solowij, N. 1998, ‘Adverse effects ofcannabis’, Blair, P.,Fleming,Bensley,D.,Smith,I.,Bacon,C.,Taylor,E.,Berry,J.,Golding,J.& Woods, S. &Raju,U. defects: 2001, ofcongenitalbirth smokingandtherisk Acohort ‘Maternal Jacobson, J. &Jacobson, S. 1994, ‘Prenatal alcoholexposure andneurobehavioural develop- Day, N. &Richardson,G. 1994, ‘Comparative teratogenicityofalcoholandotherdrugs’, Capus, C. &Holmes, J. 1997, inpregnancy’, ‘Drugs Plessinger, M.1998,‘Prenatalexposuretoamphetamines: Risksandadverseoutcomesin 138. Effects andmanagement.’, no. 1,pp.139–151. Journal Paediatric Child Health Child Paediatric Journal Childhood in Disease of Archives World, Research and Health Alcohol in newborns withfetalin newborns cocaineexposure’, exposure toalcoholandotherdrugs’ case-control studyforconfidentialinquiryintostillbirthsanddeathsininfancy’, Tripp, J.1996,‘Smokingandthesuddeninfantdeathsyndrome:Resultsfrom1993–5 ment: Where isthethreshold?’, pregnancy.’, study.’, Problems Medical Journal Medical Replacement Therapies Replacement The Journal of the American Board of Family Practice Family of Board American the of Journal The , ed. CSAHS, Camperdown, Sydney. Novak, & AlcoholDepartment, H.,Drug Obstetrics and Gynecology Clinics of North America North of Clinics Gynecology and Obstetrics ,

vol. 313,no.7015,pp.195–198. ,

Harwood AcademicPublishers, Netherlands. Obstetrics and Gynecology Clinics of North America North of Clinics Gynecology and Obstetrics Alcohol Health and Research World, World, Research and Health Alcohol , vol.37,pp.266–270. , ,

Methadone Maintenance Treatment and other Opioid other and Treatment Maintenance Methadone

[Online], vol. 85,no. 4,pp. 296–299. vol. 18,no. 1,pp. 42–48. Pediatrics

http://aspe.os.dhhs.gov/hsp/cyp/drugkids.htm. , vol. 107,no. 5. Lancet Nursing Care of Drug & Alcohol & Drug of Care Nursing ,

, vol. 14,no. 5,pp. 330–334.

vol. 352,pp. 1611–1616. , vol.25,no.1,pp.119– vol. 18,no. 1,pp. 30–36. , vol.25, British Chapter 16

Surgery and Substance Use

ATIENTS with substance use problems are common on Surgery surgical wards. People may suffer trauma while intoxicated, or vascular injury and infection from injecting drugs. PIn other cases, the substance use is unrelated to the indication for surgery and is easily missed.

Assessment for any form of surgery should involve brief assessment for any substance use issues including drug dependence. If problems are identified, intervention should commence at the ear- liest possible opportunity ideally by the treating team or via referral to drug and alcohol services. Delaying the treatment until development of avoidable post-operative withdrawal increases the costs of hospitalisation and leads to poorer outcomes.

Drug dependence is a chronic condition and consultation with a drug and alcohol specialist is advised coupled to continuing care after discharge from hospital.

Problems related to surgery in people with substance use problems include: pre-operative recognition and intervention anaesthetic problems post-operative withdrawal peri-operative morbidity and mortality management of drug seeking and drug use on the ward management of post-operative pain

193 Surgery 194 referral treatmentshouldbe offered. for further and toquitsmokinglong-term interviewing lence ofnicotinedependence. Motivational often doesnotoccurdespitethehighpreva- disease)arepresent.ischaemic heart This where nocontra-indications(suchasactive be offered whereindicatedand provided Nicotine replacementtherapy (NRT) should considered if: Post-operative nicotinewithdrawal shouldbe orreferral. intervention priate advice toquitsmokingandtheoffer ofappro- ting. shouldinclude Preparationfor surgery benefitsofquit- consideration ofthelong-term pre-operatively andmay bemorereceptive to Patients oftenaccepttheneedtoquitsmoking widely recognised. disease andpost-operative chestinfections is The associationbetween smokingandairways TOBACCO in thecaseoflatter. and dependence, andespeciallywithdrawal relatetobothintoxicationClinical concerns includes: patient abouttoundergosurgery Psychoactive substanceusetoconsiderina rial andotherfactorsrial shouldbeconsidered. Post-operative symptomsmay bemultifacto- the patientsmok stimulants benzodiazepines opioids alcohol tobacco as craving for cigarettesandirritability complains ofwithdrawal symptomssuch and ed untilthetimeofsurgery; Post-operative Morbidity Alcohol and ALCOHOL troenterologist orhepatologist isadvised. tive complicationsandassessmentby agas- sociated withmajorincreasesinpost-opera- The presenceofalcoholicliver diseaseisas- outcomes poorer Follow-up hasconfirmed aftersurgery including: A broadrange ofmorbiditiesmay occur, several respects: adversely affects post-operative outcomesin Alcohol consumptionexceeding 60gperday psychiatric comorbidity.psychiatric a palliative caresettingorthosewithsevere An exception shouldbemadefor patientsin smoking areas. help patientstoobtaincigarettesoraccess or even onhospitalgrounds. Staffshouldnot smokinginside Many hospitalsdonotpermit seekingbehaviour. asdrug can beinterpreted Attempts by in-patientstoobtaincigarettes cardiopulmonary insufficiency cardiopulmonary bleeding; and infections alcohol withdrawal syndromes higher hospitalcosts increased needfor repeatsurgery longer durationofhospitalisation significantly morecarerequired increased post-operative mortality increased totalmorbidity . Pre-operative assessment shouldinclude: m alcohol historypriortosurgery.Keyquestions It iscrucialtoobtainanaccuratedrugand alcohol problems areoftenoverlooked. staff tendtofocus onthesurgicalproblem and tune timefor intervention; however, clinical The pre-operative settingprovides anoppor- Alcohol-related Complications Peri-operative Managementof in avariety ofclinicalsettingsincluding: Adverse outcomeshavebeendemonstrated ust consider: laboratory tests: examine forsignsof: physical examination; e.g. monitor: ports andavailablepsychosocial history sup- history alcohol anddrug likelihood andseverity ofwithdrawal e.g. alchoholandbenzodiazepines cross-tolerance withotherdrugs likelihood oftolerance andpossibility of recency ofuse ofuse patterns used(licit&illicit) drugs osteosynthesis ofmalleolarfractures evacuation ofsubduralhaematoma hysterectomy colorectal surgery " " " " " ascites orencephalopathy) of decompensationsuchasjaundice, liver disease(abnormalLFTs, signs respiratory disease cardiomyopathy (rare) HR (heartrate) BP (bloodpressure) Chapter 16 tings, over-sedation must becarefullyavoided. tremensoftencoexisting.delerium Insuchset- factorial withchestinfection,hypoxiaand Post-operative confusionisoftenmulti- operative managementplan. anticipated andmanagedaspartofthepost- voidable, withdrawalsymptomsshouldbe days afterstoppingdrinking.Ifsurgeryisuna- treated alcoholwithdrawal,occurring3–14 medical emergencyassociatedwithun- ing deliriumtremens.Deliriumtremensisa lihood ofcomplicationsandriskdevelop- drawal mayincreasewithdrawalseverity,like- drawal iscomplete.Surgeryduringwith- pendent patientsuntilthecourseofwith- Surgery shouldbeavoidedinalcoholde- and describedelsewhere.Thiamineisgiven. offeredalcohol interventions inothercontexts of pre-operative treatmentdoesnotdiffer from morbidity (Tonnesen etal.,1999). The nature reducespost-operativeto elective surgery toreducealcoholconsumptionprior tervention hasshownrandomised thatin- controlledtrial it. tonormalise A isnecessary of sobriety depressed cellularimmunity, but twomonths Two weeksofabstinencefromalcoholimproves when disordersofalcoholusearerecognised. shouldbeinitiated intervention An appropriate specialist referral may berequired. If abnormalitiesarefound,pre-operative " " nesium) metabolic (BSL,electrolytes,mag- agulation studies) haematology (plateletcountandco- Alcohol See Chapter3 195

Surgery Surgery 196 to thepresenceofopioidtolerance. A higherdoseofopioidswillberequireddue appropriate. Non-opioid analgesiashouldbeusedas will beswitchedtooral. advise thepatientwhenparenteralmedication treatment earlyinthemanagementplanand Decide anappropriatedurationofparenteral drawn whennolongerindicated. provided andthatopioid analgesiawillbewith- the patientthatadequateanalgesiawillbe treatment for both. toexplain to Itisimportant appropriate orders andshouldbeprescribed may beconceptualisedassuffering twodis- Post-operative analgesiaisanissue. Patients approach isunlikely tosucceed. post-operative opioidanalgesiasothis recommended, but patientsusuallyrequire Detoxification pre-operatively hasbeen two doses1-2days before discharge. to singledailydosingby simplycombiningthe aged andiftaken up, thepatientisswitched Maintenance afterdischargecanbeencour- allows surgicaltreatmenttobecompleted. ment. Thisincreasesretentioninhospitaland maintenance oftenacceptin-hospitaltreat- Many patientswhowillnotacceptmethadone In thissetting,twicedailydosingiseffective. tal provideddrowsypatientsarenotdosed. More rapidincreasesmaybeusedinhospi- as requiredevery3days. mencing at20–40mgdailyandincreasing pre-operatively usingmethadone, com- Opioid dependenceshouldbestabilised OPIOIDS communicate thistotheGP. discontinuation onthedischargeletterand thetimefordischarge fromhospitalorwrite Where possible, discontinueopioids before dependence andexplain these tothepatient. viding analgesiathatwillnotleadtoongoing ofrelapsing.at risk Settreatmentgoalsofpro- Patients withprevious opioiddependenceare cases, inaddition tootheranalgesia. maintenance isstronglyindicatedinsuch use afterdischargefromhospital.Methadone need for toheroin analgesiaarelikely toreturn Opioid dependentpeoplewithacontinuing dischargegoal. Set anappropriate andalcoholservice. Consult thehospitaldrug circumstances changebut avoid thisotherwise. Extend theparenteral treatmentiftheclinical inadequatedoses.regular fixed dosemorphine abused. Insuchcases, switch toaregimenof thatPCAwillstopif should beinstructed be consideredaftersurgery, but thepatient ofpatientcontrolledanalgesia(PCA)mayA trial evolve seeking. intodrug seeking,ormay may asdrug beinterpreted dose isdue. Otherwise, requestsfor analgesia between staffandpatientsaboutwhenthenext rather thanp.r.n. dosingtominimiseconflicts analgesia. fixed Prescribe dosesofanalgesia longer actingopioidssuchasmor Continue orcommencemethadoneandadd

Pethidine: after highdoses which has thetoxicmetabolitenorpethidine high abusepotential has markedeuphoriceffectsandhence has ashorthalf-life is rarelyanappropr commonly precipitatesseizures iate drug inthissetting iate drug phine for

hospital mayberequired. usecontinues, dischargefromthe If drug Strategies Management should beconsidered: use Three commonreasonsfor ongoing drug practical problems. Drug useonthewardscausesethicaland this Handbook. nised andmanagedaspertheguidelinesin Drug seekingbehaviourshouldberecog- continuing dependence anxiety motivational interviewing offeredmotivational interviewing obtained andalcoholconsultationshouldbe drug methadone doseincreased exploredanxiety causesandinterventions analgesia may beincreased unrelie ved pain ‘Drug Seeking’,p.24 General Principles See Chapter2 Chapter 16 until theeffects abate. changes may leadtohaemodynamicinstability consultation.quire psychiatric Cardiovascular psychosismayproblems anddrug-induced re- of theEmergencyDepartment). Psychological major problems inhospital (with theexception Cocaine andamphetaminesarenotoften STIMULANT USE by thepatient. problem orthenumber ofdoctorsbeingseen GP whomaynotbeawareoftheextent It isimportanttocollaboratewiththepatient’s This isslowly withdrawn over ensuingweeks. required tosuppresswithdrawal symptoms. diazepam, issubstitutedattheminimum dose A singlelong-actingbenzodiazepine, usually in otherclinicalsettings. managed asfor benzodiazepine dependence operative period. Insuchcases, thepatientis ten presentswithwithdrawal thepost- during patient doesnotdiscloserecentuse. This of- isnottaken orthe history if acarefuldrug Benzodiazepine dependencemaybemissed BENZODIAZEPINES Benzodiazepines See Chapter11 197

Surgery Surgery 198 Tonnesen, H.,Rosenberg,J., Nielsen,H.J., Rasmussen, V., Hauge, C., Pedersen I.K. &Kehlet, REFERENCES H. 1999, British Medical Journal Medical British , vol.318,pp.1311–6. Chronic Pain Chronic Pain Managing Managing Managing Chronic Pain Chronic Pain Chronic Pain Managing Managing Chapter 17 Chapter 17 Chapter 17 Chapter 17 Chapter 17 M M minimise the risk ofsideeffects.minimise therisk possible durationand forpossible theshortest doseofadrug on thecardinalnotionof istousethelowest ‘first donoharm’, than chronicconditions. oftherapeutics, founded Abasicprinciple The medicalmanagementofpainisfar moresuccessfulinacute ACUTE ANDCHRONIC PAIN M Clinical objective: Aim: ment of a trusting therapeutic relationship.ment ofatrusting A carefulexplanation oftheclinical problemasisdevelop- iscrucial, M M

plasma analgesicconcentrations avoid temporarysedationoreuphoria coincidingwithpeak concentration avoid peaksofpain duringanadirintheanalgesic’s plasma constant reduce paintolevelsthatarebearableandreasonably or avoidseriousanalgesicsideef keep thepatientascomfortablepossibleandminimise ANAGING ANAGING ANAGING management ofacuteandchronicpainfulconditions. Provision ofeffective ofthemedical analgesiaisonlypart ANAGING ANAGING chronic painisincreasinglychallenging. fects Chapter 15 199 199 199 199 199

Chronic Pain Chronic Pain 200 200 200 200 200 of oral morphine ororal oxycodoneof oral and metha- morphine long actingopioids It isgenerallyagreed thatorally, well-absorbed, patients withchronicpaindo ment ofchronic, non-malignantpain,many While opioidshaveanimportantroleintreat- lief incasesinvolvingmildpain. Paracetamol oraspirinprovideexcellentre- ence ofhighdosesorrenalimpairment. ing complications,especiallyinthepres- pethidine metabolitescanaccumulatecaus- with seeking behaviouranddependencethan be complicatedby severe problems ofdrug tion ofpethidineinjectionsismorelikely to with fewer sideeffects. prescrip- Long-term algesics provide moreeffective painrelief chronic painmanagementbecauseotheran- Pethidine injectionsshouldbeavoided for tions fluctuatewidely. clinicaloutcome, asplasmaconcentra- term of theseagentsoftenachieves apoorlong- management ofchronicpainwithinjections cellent painreliefinacuteconditions. But actingopioidsprovide ex- Injections ofshort sions orskinpatchratherthanby injection. administered by mouth,suppository, infu- time isachieved iflongeractingagentsare A moreeven concentrationofanalgesicsover of substanceabuse. all, for patientswithacurrentorpasthistory But opioidsshouldbeusedwithcaution,ifat factors of opioid dependence. areatlow risk Chronic painpatientswithoutpre-existingrisk efit isequivocal. lignant conditions, evidence ofsignificantben- in managementofpainful,chronic, non-ma- opioids. Althoughopioidsarecommonlyused morphine orotheropioids.Also,active www.ebandolier.com , sustainedreleaseforms not require Assessment ofthechronicpainpatiententails: A comprehensiveinitialassessmentispivotal. ment (e.g.theNHMRCguidelines). guidelines andprotocolsforpainmanage- patients, but thereareexcellent general management specificallyfor drug-dependent tocol toguidestandardsofpractice inpain recognisedtreatmentpro- There isnoformally IN DRUG USERS PAIN MANAGEMENT ASSESSMENT AND analgesia provided by opioids. analgesic effects oftheirown but augmentthe sants oranticon Adjuvant suchassomeantidepres- drugs, pain. Theseoptions: of moderatetoseverechronicnon-malignant done, arefirstlineagentsforthemanagement anxiety disorders psychiatric historytoidentify moodand and/or othersubstanceabuse ofalcohol current, pastorfamily history pathology investigations todocumentorganic physical examination full history pre provide great flexibility be readilymodifiedaccordingtoneed allow thesizeandfrequencyofdosesto avoid theneedforinjections low peaksandshallow troughs provide relatively even reliefover timewith vious records publications www.nhmrc.gov.au/ vulsants, have nosignificant WHO AnalgesicLadder WHO AnalgesicLadder Figure 17–1 Figure 17–1 WHO AnalgesicLadder Figure 17–1 Opioids shouldbeusedwithcautionif: dependence. ofsubstanceabusepast orfamily or history All patientsshouldbescreenedfor acurrent, Substance Dependence Screening for Source: WorldHealthOrganization WHO AnalgesicLadder WHO AnalgesicLadder Figure 17–1 Figure 17–1 > 4standarddrinks/day(women) > 6standarddrinks/day(men), alcohol : positive CAGE current copingstrategies and stressors social historyincludingsupportsathome ‘CAGE’, p.42 Alcohol See Chapter3 Chapter 17 Chapter 17 Chapter 17 Chapter 17 Chapter 17

are considered: management ofchronicpainbefore opioids There aremanyoptionstoexploreforthe in Management Alternative Options

opioid orbenzodiazepineuse previous long-term,heavyprescription regular useofillicitdrugs ladder (seeFigure17–1) salicylates —followtheWHOanalgesic inflammatory agents(NSAIDS), other analgesicse.g.non-steroidalanti- physiotherapy behavioural therapy supportive counselling,cognitive– in worktasks lifestyle adjustment;e.g.exercise,change 201 201 201 201 201

Chronic Pain Chronic Pain 202 202 202 202 202 ence (includingtolerance): or benzodiazepines),canresultindepend- other psychoactivesubstances(e.g.alcohol (e.g. heroin,morphineormethadone)and (CNS) depressantdrugs,includingopioids Consumption ofcentralnervoussystem Dependence and Tolerance sidered response Better outcomesrequireathoughtfulandcon- agement f Issues tobeconsideredimprove painman- otherapists andpainspecialists. nurses, psychologists, physi- psychiatrists, pain managementisoftenhelpful,in A teambased,holisticapproachtochronic dependence sumption increaseseverity ofdrug higher dosesandlongerdurationofcon- prescribers real andperceivedlegalconstraintsfor cians andallpatients arise incommunicationbetweenclini- difficulties andmisunderstandingswhich sedative drugs potential adverseinteractionswithother tolerance toanalgesics radiotherapy lation (TENS) Transcutaneous ElectricalNerveStimu- local anaesthetics corticosteroids antihistamines antispasmodics muscle relaxants anxiolytics, tranquillisersandhypnotics anticonvulsants antidepressants or injectingopioidusersinclude: . volving

required tomaintainusualeff effect overtime(orhigherdosesofadrugare Tolerance meansthatadrugdiminishesits competition tosomeextent. and suffering.Theseobligationsareoftenin against thecriticalobligationtorelievepain should always beahighpriority, but balanced Preventing dependencefromdeveloping drug Non-malignant Pain in PatientsChr with Preventing DrugDependence sedation. or benzodiazepines, may resultinexcessive nervous systemsedatives,includingalcohol properties inthepresenceofothercentral ofananalgesicwithsedative Prescription to pain. exposure toopioidsmay alsoreducetolerance Some recentevidence suggeststhatchronic ofprevious opioiduse.history and bodyweight withasimilarfracturebut no duration thanapatientofthesameage, sex administered morefrequentlyandfor alonger merus, willrequirelargerdosesofpainrelief heroin usepresentingwithafracturedhu- For of example, patientswithalonghistory patient withanidenticalphysical condition. analgesiacompared toanopioid-naive tory inordertoachievelonger periods satisfac- opioid analgesiamorefrequentlyandfor a painfulconditionrequirelargerdosesof People whoareopioidtolerantanddevelop enon andcanonlybeestimatedapproximately. a relativeratherthananall-or-nonephenom- when consumptiondeclinesorceases dependence andtolerancedecrease ect). Toleranceis onic dependence: ofdrug help reducetherisk also The following principles pharmacological Minimise theriskofdrugdependenceby: opioids with a shorter half-life, suchas opioids withashorter onset ofmaximaleffect. Orally well-absorbed days betweentheinitiationof treatmentand there isaninevitabledelayofuptoseveral The longhalf-life ofmethadone meansthat areeasiertousethanmethadone.tive drugs between patients. Othersarguethatalterna- inhandlingthedrug substantial variability andthe ofthedrug macological properties clinicians arefamiliar withtheunusualphar- be achieved usingmethadoneprovided that arguethatexcellent reliefcan Some experts chronic painfulconditionsiscontroversial. Use ofmethadoneinthemanagement Patientsin OpioidDependent Principles ofPain Management solete preparations. avoid pethidineinjectionsandotherob- actingopioids rather thaninjectable short use non-injectable longactingopioids duration foruse lower ashorter dosesofadrug to respondthesepatients. ably betterequippedandhave moretime available,the range ofmaterials areprob- malignant pain. They aremorefamiliar with interested inmanagementofchronicnon- ing numberofalliedhealthprofessionals referring patientstooneofasmallbut grow- chronic pain bookletsforand explanatory patientswith cluding relaxationtapes, discussiongroups A growing listofaidsisnow available in- cological painmanagementmeasures. maximising thebenefitsofnon-pharma- ent onanalgesicmedication doctor arelesslikelytobecomedepend- a strongtherapeuticrelationshipwiththeir fully understandtheirconditionandhave keeping patientsinformed.Patientswho Chapter 17 Chapter 17 Chapter 17 Chapter 17 Chapter 17 release oralmorphinepreparation. Afurther gesic, suchasoxycodone, or a sustained through theadditionofanother opioidanal- Improved painreliefcanoftenbeachieved an alreadycomplicatedtreatmentsystem. eral days toachievecomplicates andfurther done hasdeveloped but thisoftentakes sev- additional analgesiawhentolerance tometha- creasing thedoseofmethadonedoesprovide in methadonemaintenancetreatment.In- for acuteorchronicpaininpatientsenrolled ofanalgesia form not beusedastheprimary It isgenerallyacceptedthatmethadoneshould maintenance Methadone dose remainsreasonable. avoid mishapandensurethatthetotalopioid dependence, closeliaisonisimperative to agement ofpainandmanagementdrug If different doctorsareresponsible for man- ings fromspecialinvestigations. be unaccompaniedby physical signsorfind- symptomsofacondition known to spurious analgesics fromdoctorsby complainingof usersdeceitfullyattempttoobtain ing drug medical staffmay considerthatsomeinject- dependence. ofdrug a history Likewise, some provide inadequateanalgesiatopatientswith often withgoodreason,thatmedicalstaffmay usersfeel, helpfulasmany injectingdrug larly Explaining theseissuestopatientsisparticu- severity ofeachone. fied separatelyaccordingtothefluctuating lems, thedoseofmedicationcanbemodi- agents arebeingusedtocontroltheseprob- problems isusuallyquitedifferent.Ifdifferent clinical sensebecausethetimescaleofthese of heroindependence.Thismakesgood rate painmanagementfromthe Some cliniciansandpatientsprefertosepa- last forashortperiod. cially ifthepainfulconditionislikelytoonly oxycodone, areusuallymoreeffective,espe- 203 203 203 203 203

Chronic Pain Chronic Pain 204 204 204 204 204 only consideration. alleviation ofpain becomesthe short, very concern. Whenlifeexpectancybecomes drug dependencebecomesasecondary become paramount. Fear ofexacerbating toalleviatethen efforts painanddiscomfort illness, ofaterminal painful conditionaspart dependentpatientsdevelopIf drug aseverely illness Terminal from disclosure. dependentpatient fears repercussions drug of heroinisoftenunreliab N.B. regardingthemostrecentuse Information will require: not beenconsumedrecently. The decision provided thatlargedoses ofany opioidhave severe pain inpatientstolerant toopioids— potentanalgesiceffectivevery inmanaging withdrawal symptoms. isa Buprenorphine unpleasantopioid cantrigger buprenorphine (i.e. of naltrexone like) properties e.g. >40mgofmethadone, theantagonist ence ofmoderatetohighdosesopioids, buprenorphine.be prescribed Inthepres- of methadoneorany otheropioidshouldnot Patients receivingmoderateorhighdoses Buprenorphine effect oftheprimaryanalgesic. in combinationwithopioidsaugmentthe cases ofsevereacutepain.Adjuvantdrugs which canbeadministeredbyinjectionin such asdiclofenac.KetorolacisaNSAID alternative isprescribingalongactingNSAID the duration sincethelastdosewas taken the half-lifeofopioid consideration ofthedoseotheropioid le, especiallyifthe ment hasdeveloped. benzodiazepines untilalmost terminal impair- manage withusualdoses ofopioidsor with evenquiteseverehepaticimpairmentto capacity oftheliverenablesmostpatients side ofcaution. In practice, thelargereserve Health professionals shouldalways erronthe metabolites. impaired hepaticfunctionduetoactive than expected effects insomepatientswith and temazepam, may alsoproducegreater Some benzodiazepines, suchasdiazepam should becarefullymonitored. increased whilesedative effects ofthedrug patients shouldbereducedandthefrequency fordose ofopioidanalgesicsprescribed these ment increasestheeffects ofmany opioids. The prescribed.ticular drugs Severe liver impair- severity andthepar- ofthehepaticimpairment in patientswithliver diseasedependsonthe The likelihood ofadverse effects ofanalgesics progression ofliver disease. to low levels orabstainasalcoholincreases encouraged toreducealcoholconsumption and safer. People withhepatitisCshouldbe avoided asotheragentsaremoreeffective The useofalcoholtorelieve painshouldbe people withliver disease. mol canbeusedquitesafely for painreliefin containingsmallquantitiesofparaceta- Drugs liver damagecanensue. disease asfurther cetamol i.e. >4grams/day inpatientswithliver Avoid long-termuseoflargedosespara- effect.ing ordecreasingtheobserved able potentiallyincreas- tometabolisedrugs, opioid analgesics. Animpairedliver isless includingmost and eliminationofmany drugs, The liverhasacentralroleinthemetabolism ADVERSE INTERACTIONS THE POTENTIALFOR been offered. the pretencethateffectiveanalgesiahas Placebo drugsshouldneverbeprovidedin advice frommoreexperiencedcolleagues. caseshouldseek course ofactioninaparticular abouttheproper Doctors whoareuncertain paramount objective. relieving sufferingshouldalwaysbethe Providingcannot beignored. comfortand ofexacerbating dependence about therisk effective painrelief. Professional concerns proper professional managementincluding as any otherpatientwithsevere painto People whouseillicitdrugsareasentitled health careproviders. individuals fromseekingassistance undoubtedly prevents dependent somedrug Fear ofpoortreatmentanddiscrimination RELATIONSHIP THE PATIENT–CLINICIAN mythology tothecontrary. urban notwithstanding injecting drugusers, Methadone doesnotcauseliverdamagein Chapter 17 Chapter 17 Chapter 17 Chapter 17 Chapter 17 ing thesemattersinanopenmannerwill: solved issuesassoonpossible.Discuss- frequently andresolveanyconflictorunre- nicians shoulddiscusspainreliefopenlyand When treatingdrugdependentpatients,cli- tory requirements. havehealth authorities tocarefullyfollow statu- known tobeaddicts’ensuresthatdoctorsand prescription of‘drugsaddictionforpersons In somejurisdictions,legislationcoveringthe dependentpatients. habitsfor drug prescribing state regulatoryauthoritieswillcriticisetheir A commonconcernamongstdoctorsisthat nature ofthepain. abouttheorganicordrug-seeking certain some caseswherethedoctorremainsun- NSAIDs orbuprenorphinemaybeusefulin

increase thechanceofde adequate painrelief toachieveadditional illicitandlicitdrugs feeling theneedto ‘self-medicate’ with decrease thelikelihood ofthepatient sumers alike; and outcome for treatmentproviders andcon- increase thelikelihood ofa goodtreatment increase patientcompliance ductive patient–clinicianrelationship veloping apro- 205 205 205 205 205

Chronic Pain Chronic Pain 206 206 206 206 206 Graziotti, P.J.&Goucke,C.R.1997‘Theuseoforalopioidsinpatientswithchronicnon- Bamingbade, T.A.&Langford,R.M.1998,‘Theclinicaluseoftramadolhydrochloride’, Hagen, N.,Flynne,P.,Hays,H.&MacDonald,N.1995,‘Guidelinesformanagingchronic Haddox, J.D.,Joranson,D.,Angarola,R.T.,Brady,A.,Carr,D.B.,Bronsky,E.R.,Burchiel,K., Bell, J.1997,‘Australiantrendsinopioidprescribingforchronicnon-cancerpain1986– RESOURCES DASC (DrugandAlcoholServicesCouncil)1996, Centre for MentalHealth2001, Jadad, A.R.,Carroll,D.,Glynn,C.J.,Moore,R.A.&McQuay, H.J.1992,‘Morphinerespon- Harris, N.,Hugh,G.&Greenway,S.(unpublished),‘EmergencyDepartmentMentalHealth Portenoy, R.K.1996, ‘Opioid therapyforchronicnon-malignantpain: a reviewofcritical Moulin, D.E.,Lezzi.A.,Amireh,R.,Sharpe,W.K.J.,Boyd,D. &Merskey,H.1996,‘Randomised cancer pain:managementstrategies’, led analgesia’, siveness ofchronicpain:double-blindrandomisedcrossover studywithpatient-control- Manual (Draft)’,NSWHealthDepartment. November 2000. 49–53. non-malignant pain:opioidsandotheragents’, the AmericanAcademyofPainMedicineandSociety’. 1997, ‘Theuseofopioidsforthetreatmentchronicpain.Aconsensusstatementfrom Gitlin, M.,Midcap,Payne,R.,Simon,D.,Vaswleuan,S.,Wilson,P.&Portnenoy,R.K. 1996’, issues’. trial oforalmorphineforchronicnon-cancerpain’,Lancet, vol.347,pp.143–147. Complaining of Severe, Recurrent or Chronic Pain Chronic or Recurrent Severe, of Complaining nal of Pain of nal Guide, Reviews publications www.nhmrc.gov.au/ Medical Journal of Australia Australia of Journal Medical www.ebandolier.com (Pocket Version),NSWHealthDepartment,August. Journal of of Journal , vol. 5,pp. 155–182. , vol.13,no.1,pp.6–8. Lancet Pain & Symptom Manage Symptom & Pain , vol.339,pp.1367–1371. Mental Health for Emergency Departments – A Reference A – Departments Emergency for Health Mental , vol.167,pp.26–29. Medical Journal of Australia of Journal Medical Guidelines for the Management of Patients of Management the for Guidelines ment Canadian Family Physician Family Canadian , DASC,Adelaide. , vol. 11, , pp. vol. 11, 203–217. , vol.167,pp.30–34. Clinical Jour- Clinical , vol.41,pp. Pain Mental Illness Coexisting Chapter 18 EPIDEMIOLOGY T bipolar disorderandschizophrenia (Todd,2002). people withantisocialpersonalitydisorder,andtoalesser extent ence asubstanceusedisorder,withhighestratesreported in people withmentalhealthdisorders, between30and50%experi- 20–30% (Todd, 2002). The evidence alsosuggeststhatfor most lation (ABS, 1998; Jablenski et al.,2000),andlifetime prevalence with amentaldisorderisestimatedtobe10%ofthegeneral popu- all, the12monthprevalence ofasubstanceusedisordertogether Prevalence greatlyacrossdifferent rates vary populations. Over-

of suchproblems arethat: forms ofmentalhealthproblems. featuresThe characteristic HERE prehensive treatment best outcomesareachievedthroughintegratedandcom- treatment ofteninvolvesarangeofdifferentservices;but ment approachesareused experience higherdropoutrateswhenstandardtreat- they areassociatedwithpooroutcomesandindividuals they areheterogeneousandvariableinnature they arecommon is ahighlevelofcoexistingAODproblemsandvarious 207

Mental Illness Mental Illness 208 including: Various areused,ofteninterchangeably, terms TERMINOLOGY impact onmentaldisorders. (e.g.nostic criteria for dependence)may still usethatdonotmeetdiag- ofdrug patterns ported prevalencelevels.Consumptionand Definitions appliedalsogreatlyimpactonre- drug use”,Pagliaro,A.& L.(2000) Source: adaptedfrom“Table ofdisorderscommonlyassociatedwithpsychoactive Mental healthproblemscommonlyassociatedwithpsychoactivedruguse Table 18–1 comorbidity coexisting mentalillness coexisting disorders dual diagnosis Psychedelics Nicotine Cocaine Caffeine Amphetamines CNS Stimulants Inhalants Solvents and Sedative/Hypnotics Opioids CNS Depressants Psychoactive Drugs

Amnesic

Disorder

Anxiety Disorder

Delirium meanings. Forexample, ‘ alsohavedifferent terms slightlydifferent No termisconsistentlyusedorfavoured.The problem and plies theexistence ofanalcoholorotherdrug Table 18–1anddetailedbelow. Some commoncombinationsareshown in tails ofthespecificcombinationproblems. treatmentrequiresde- disorders appropriate of theheterogeneousnaturecoexisting range ofcombinations ofproblems. Because Coexisting disordersencompassawide ASSOCIATIONS SOME SPECIFIC at leastonementalhealthproblem. mean theco-existence ofanAOD problem and

Mood Disorders one

Psychotic otherproblem. Butallterms Disorders

Sexual diagnosis’ dual Dysfunction

Sleep Disorders im- those withapredispositiontothedisorder. cipitate onsetofschizophrenic psychosisin intoxication subsides. Cannabismay alsopre- episode thatcanlastseveral days afterthe nabis may infrequentlyinduceapsychotic mild psychoticsymptomse.g. paranoia. Can- psychosis withcannabisuseis A commonexperience and Cannabis when unwell. behaviourlems andhigherratesofdisruptive use, increasedsymptoms, more medicalprob- tonon-adherencemedication contributes Amongst thosewithschizophrenia alcoholuse lusions inthosewithpsychoticdisorders. ofhallucinations andde- with increasedrisk Problematic alcoholusehas beenassociated psychosis and Alcohol a manicphase. of thecycleandlikelihoodrelapseduring also confoundtreatment,increasingtherate disorder isalsocommonandalcoholmay lowing severalweeksabstinence.Bipolar order. Depressionisgenerallyresolvedfol- disorders Commonly associatedwithadepressivedis- mood and Alcohol From aDrugsPerspective whether thisoccursonlyinthose withapre- chronic heavyamphetamineuse (itisunclear schizophrenia-like conditionmay occurafter up toseveral weeks. Occasionally, achronic tion, usuallyfor several days but sometimes sis canexist beyond ofintoxica- theperiod symptoms. Anamphetamine-induced psycho- mines) canresultinanumberofpsychiatric Intoxication fromstimulants(e.g. ampheta- and Stimulants anxiety disorders. clude depression,socialphobiaandother disorders accompanies opioiddependence. These in- health highrate ofmentalhealthconditions A very mental and Opioids mental health disorders health mental Chapter 18 symptoms whenthedrugisusedagain. sensitises theusertounwantedpsychotic existing disposition).Heavyprolongeduse compulsive. line, narcissistic,avoidantandobsessive– stance misuseincludethehistrionic,border- tion. Otherpersonalitydisorderspronetosub- Antisocial personalityisacommonassocia- and disorders Personality a patientwithananxietydisorderwhen: Also considermisuseofbenzodiazepinesin treating anxietydisordersisoptimal. dependent people.Ceasingdrugusebefore der andsocialphobiaarecommoninalcohol of analcoholordrugsyndrome.Panicdisor- ever, anxietydisordersalsocanoccuraspart use high ratesofalcoholanddrugproblems.How- drug and People withanxietyordersalsoexperience disorders Anxiety Perspective From aMentalHealth and illnesses Psychotic

substance use disorders use substance substance use problems use substance provoking situations to overcomenearlyallpotentiallyanxiety- there isextensiveuseofbenzodiazepines treatment approaches the patientisreluctanttoconsiderother symptoms persistdespitetakingthem & Hall,2001) pendent thanstudycontrols(Degenhardt times respectivelymorelikely tobede- chotic illnessesarefivetimes andthree users ofalcoholandcannabiswithpsy- orders slower recoveryfromsubstanceusedis- worse psychosis,poorcomplianceand creased ratesofviolence,homelessness, people withpsychoticillnesseshavein- 209

Mental Illness Mental Illness 210 What Works? nature oftreatmentforcoexistingdisorders. There isgrowingconsensusregardingthe MANAGEMENT misuse substance and Suicide stance use non-confrontational approachestosub- ceptable both areasarethemosteffective andac- by therapistswithskillsandknowledge in and integrated approacheswithinservices suicide by: substance misusepredisposesto suicides drugs atmeasurablelevelsin30–50%of post-mortem studiesfindalcoholorother but theyexacerbatepsychosis ferred bypatientswithpsychoticillnesses stimulants andhallucinogensarepre- nesses symptoms inthosewithpre-existingill- able individualsandwillexacerbate precipitate psychoticillnessesinvulner- likely tocauseachronicpsychosis.Itcan symptoms ifusedinlargedosesbutisun- cannabis mayproduceacutepsychotic " " " " ment ifneeded assertive careandinvoluntarymanage- worsening moodorpsychosis natives clouding ofone’sabilitytoseealter- through theact overcome resistanceincarrying disinhibiting orproviding‘courage’to .Treatmentintegration—involvestreat- 5. Clinicalcasemanagement —often 4. Comprehensive assessment—isessen- 3. Stabilisation—addressacuteintoxication 2. Safety—aboveallelseensurethesafety 1. Principles ofCare Treat 4. treatment long-term for Engage 3. disorders both for Screen 1. Assessment andManagement .Assess 2. health condition ment forboththedruguseandmental quires coordinationandcontinuityofcare initiated bymentalhealthteambutre- tial andisanongoingprocess symptoms etc. severesocial crisis, anxietyordepressive or withdrawal, psychoticsymptoms, psycho- of thepatientandothers better whendrug-free change unlesstheirlivesare going tobe controlled schizophrenia areunlikely to realistic outcomese.g. patientswithpoorly establish motivation tochange, goalsand some mentalhealthproblems iscommon. vital but difficult. Relapsefor AOD and " " " ask: multiple reviews over timemay beneeded needed manage withdrawal andreassessif athoroughassessment undertake have hadtimetoresolve(seebelow). and substanceinducedsymptoms has withdrawnfromthesubstance effects havedissipatedandthepatient observe mentalstateafterintoxication nence? during periodsofprolongedabsti- were thepsychiatricsymptomsthere which camefirst? disorders both to Attend 5. be animprovement orvalid endpoint. also acknowledges incrementalchange can butabstinence fromalcoholorotherdrugs, it ues. minisationapproachmay involve Aharm usecontin- jecting equipmentifinjectingdrug alcohol dependence, oraccesstocleanin- example, ofthiaminefor ensureprescripton minimisationapproach,forApply aharm Harm Minimisation azepam perday. fective iftakingmorethan5–10mgofdi- graded exposure for agoraphobia isinef- and anxietywhentaken withalcohol, pressants arelesseffective for depression substance misusecontinues e.g. antide- effective (but nottotallyineffective) when treatmentsareless generally psychiatric weekly pick upfromapharmacist/clinic daily collectionwithmethadone, ortwice providing limitedquantitiesatatimee.g. relative tothepossible benefits. Consider antidepressants aresmall and modern problems ofinteraction between alcohol sants andalcoholarebestavoided. The forscribed, example, antidepres- tricyclic substance usedandthemedicationpre- patients, but cautiously; dependingonthe medicationtosubstanceusing prescribe alcohol ten goesoncethepatientisabstinentfrom sis iswellcontrolled,anddepressionof- usedecreaseswhenpsycho- often drug perspective.adopt along-term coexisting mentalillnesses) quently overlookedforpatientswith minimisationstrategies (fre- apply harm specialist agencywhereappropriate) proach forillandrefer psychiatrically toa motivational enhancement(modifiedap- Chapter 18 211

Mental Illness Mental Illness 212 Holmwood C.2003,‘Comorbiditywithmentaldisordersandsubstanceuse:Abriefguidefor RESOURCES McCabe D.&HolmwoodC.2003,‘Comorbidityingeneralpractice:Theprovisionofcarefor the primarycareclinician’. www.health.gov.au/pubhlth/publicat/document/comorbid_gp.pdf practitioners’. people workingwithcoexistingmentalhealthproblemsandsubstanceusebygeneral from: www.health.gov.au/pubhlth/publicat/document/comorbid_brief.pdf www.mentalhealth.org FUSA/PARC/Publications www.som.flinders.edu.au/ Commonwealth Department of Health and Ageing. and Health of Department Commonwealth Commonwealth Department of Health and Ageing and Health of Department Commonwealth Accessedfrom: . Accessed Degenhardt L.&HallW.2001,‘Theassociationbetweenpsychosisandproblematicaldrug ABS (Australian BureauofStatistics)1998, REFERENCES Todd, F.2002,‘Chapter20:Coexistingalcoholanddrugusementalhealthdisorders’in Jablenski, A.,McGrath,J.,Herrman,H.,Castle,D.,Gureje,O.,Evans,M.,Carr,V.,Morgan, Pagliaro, A.&L.2000, Well-Being’. use amongAustralian adults: findingsfromtheNationalSurvey ofMentalHealthand (ed.) HulseG., White, J. &CapeG. 2002, p. 183. Study onLowPrevalenceDisorders’, Korten, A. &Harvey, C. 2000, ‘Psychotic disordersinurbanareas: anoverview ofthe vol. 34,pp.221–236. Oxford UniversityPress,SouthMelbourne,Victoria,pp.359–373. of Adults: User’s Guide User’s Adults: of Psychological Medicine Psychological Chapter 18 , ABS, Canberra. Substance Use Among Women Among Use Substance , vol.31,pp.659–668. Australian & New Zealand Journal of Psychiatry of Journal Zealand New & Australian National Survey of Mental Health and Wellbeing and Health Mental of Survey National Management of Alcohol and Drug Problems Drug and Alcohol of Management , Brunner/Mazel,Philadelphia, ; , 213

Mental Illness Mental Illness 214 Chapter 19

Chapter 15 Injecting and Communicable Diseases Diseases Communicable

HE REALITY of the human immunodeficiency virus (HIV) and hepatitis C (HCV) epidemics has served to clarify thinking Tabout the risks of acquiring communicable diseases through injecting drug use. Hepatitis B (HBV), which poses a significant risk to the injecting user population, did not have such an impact and only now is its importance in this population being recognised.

With reliable estimates predicting an increasing use of illicit drugs, there is an urgent need to provide clear and unequivocal messages about the risks of infection associated with these practices.

Recent studies have demonstrated that all of the paraphernalia linked to injecting use have the potential to transmit blood borne infectious agents. Even if sharing of equipment does not occur, poor cleaning of personal equipment and contaminated drug supplies can still expose the individual user to infections from bacteria and fungi.

215 INFECTIVE PROBLEMS HEPATITIS C ASSOCIATED WITH INJECTING DRUG USE This is the most commonly transmitted patho- genic virus in Australian IDU populations. The annual risk of hepatitis C (HCV) endocarditis. While infection of the tri- seroconversion in regular users is 15% and cuspid valve is more common, left sided for those who have used for more than 10 subacute bacterial endocarditis (SBE)

Diseases years rates of HCV positivity reach > 90%. regularly occurs in injecting drug users (IDU). Staphylococcal and fungal infections (left sided) are well recognised Some facts about HCV:

Communicable ophthalmitis approximately 15,000 new cases of HCV systemic candida infections occur in Australia per annum bacteraemia most of these will occur in IDU settings tuberculosis transmission occurs through blood con- tamination of equipment tetanus sexual transmission occurs uncommonly vertical transmission occurs in 5–8% of HCV RNA positive mothers (recent data BLOOD BORNE suggests caesarian section may reduce COMMUNICABLE DISEASES the risk) no evidence of transmission from breast Numerically these infections are more signifi- feeding cant. They include: hepatitis C Testing for HCV hepatitis B HCV antibody (HCV Ab) remains the first hepatitis D line test but it does not distinguish between acute, chronic or resolved infection. HIV HCV Ab is passively transferred to HTLV–I/II neonates who will remain Ab positive for malaria up to 12 months HCV Ab becomes positive 15–30 weeks There is a real possibility that other, as yet post-exposure unidentified, viruses exist. HCV RNA detectable within 2–3 weeks of exposure to the virus Hepatitis G (HGV) antibodies are found in HCV RNA now funded by Medicare in sus- approximately 10% of injecting users but the pected acute HCV infection and in patients significance of this virus remains unclear. with persistently normal liver tests (to con- Transfusion-transmitted virus (TTV) antibod- firm viral clearance). Testing also approved ies are also common but neither HGV nor TTV in pregnant patients co-infection alter the course of HCV or HBV

infection. HCV genotype and viral load now funded by Medicare in relation to commencing treatment. These tests may be ordered by a GP who is linked to a treatment centre

216 Chapter 19

Natural History combination therapy is contraindicated in the presence of overt or suspected coro-

up to 30% of infected individuals clear the nary artery disease. Interferon may exac- virus within 12 months erbate autoimmune disease. Thyroiditis, 10–15% of chronically infected individu- which can progress to thyroid failure, oc- als progress to cirrhosis over 20–30 years. curs in approximately 20% of interferon Risk of cirrhosis is increased by: treated patients " older age at infection Diseases " male Managing Patients who have " alcohol > 40 g / day Failed Therapy or are " Ineligible for Treatment possibly increasing age Communicable risk of liver (hepatocellular) carcinoma monitor liver function 6 monthly (HCC) is approximately 4% per annum in repeated HCV RNA tests are only indicted cirrhotic patients if liver tests change significantly

most patients with HCV will not die of HCV in cirrhotic patients monitor a fetoprotein related complications 6 monthly and perform abdominal ultrasounds 6 monthly to detect HCC de- Assessing Patients velopment for Treatment consider HBV and HAV vaccination although cost-effectiveness studies do not S100 guidelines for antiviral therapy specify favour universal recommendation a subset of patients that may access treatment. The following tests are required before treatment may be initiated and they can Liver Transplantation in HCV be ordered by GPs evaluating patients. HCV end stage liver disease is the most A Referral Checklist is at Appendix K of this common indication for liver transplantation Handbook. in most Western countries reinfection of the graft occurs in all patients See Appendix K and cirrhosis evolves in approximately 10 years

Antiviral Therapy Prevention of HCV interferon monotherapy is no longer re- do not share any injecting equipment or garded as appropriate unless patient is paraphenalia unable to tolerate ribavirin reduce injecting drug use, encourage if interferon monotherapy is to be used it routes of non-injecting administration and should be with pegylated forms of the encourage users to quit use through treat- molecule as they provide significantly im- ment programs proved sustained response (SR) rates fast track pregnant patients with HCV onto (approx 40%) a methadone program

interferon-ribavirin therapy gives an over- in household settings: do not share razors, all SR in 40–50% of patients with non 1 toothbrushes or other items that may be genotypes achieving up to 80% SR contaminated by blood wear gloves when cleaning blood spills avoid at-risk sexual exposure

217 Alcohol and HCV Testing for HBV high daily intake will markedly worsen liver interpreting HBV tests should always be tests undertaken carefully > 40 g / day will increase rate of progression serological tests include HbsAg, HbsAb, to cirrhosis HbcAb, HbeAg and HbeAb do not consider treatment in those drinking with mutant strains now more common it > 40 g / day as response is reduced and is possible to have mutants that produce Diseases ALT may normalise in some if alcohol is no HBeAg and even no HBsAg ceased HBV DNA measurement is becoming more useful and even necessary Communicable HEPATITIS B Natural History hepatitis B will produce a fulminant hepa- Exposure to this virus is common in certain titis in < 1% and a clinical illness in < 50% countries and in certain groups within the of infected individuals Australian community. Unlike HCV infection, immunity to HBV is life-long but wild strain only 5% become chronically infected. Children immunity may not protect against mutant infected at birth have a much higher chronicity strain infection rate (approximately 80%). Evidence of expo-

sure to HBV is found serologically in 40–50% neonatal infection usually results in the of IDUs in Australia. ‘asymptomatic’ carrier state with HbsAg positivity and normal liver tests. Some individuals develop ‘flares’ of abnormal

HBV now exists in our community in a wild ALT and may progress to cirrhosis and a mutant form. Co- or re-infection can the asymptomatic carrier may still progress thus occur to hepatocellular carcinoma without

HBV may be transmitted from blood expo- cirrhosis sure but also sexually and by exposure to other infected bodily secretions Treatment of HBV prevention of HBV will be achieved by applying guidelines included in the HCV the release of lamivudine on S100 has section modified treatment significantly an effective HBV vaccine exists and it available for 12 months therapy to those should be recommended to all at risk of whose biopsy shows chronic active this infection hepatitis currently in Australia HBV vaccine is made therapy does induce the development of available free to: resistant (YMDD) mutants " all newborn babies if transplantation is being considered then " adolescents who missed vaccination lamivudine monotherapy should not be at birth commenced without discussion with a transplant unit " health care workers through their place

of employment interferon monotherapy can be used and 20–30% may be expected to lose HBeAg " attendees at sexual health clinics and become HBeAb positive. Only 5–7% will clear HBsAg

218 Chapter 19

HEPATITIS D maculo-papular rash recent evidence of sexually transmitted Fortunately this infection is becoming less fre- infections quent in the Australian community. HDV is an recent high-risk exposure incomplete viral particle that requires the HBsAg coat to allow it to infect hepatocytes. Testing for HIV HIV serological tests may be positive 3 weeks HDV can only infect HBsAg positive indi- Diseases viduals after the start of a primary HIV illness

infection may be a co- or super- infection HIV DNA may be detectable within a few days of symptoms and negative at 1 month in either instance the disease in the dually Communicable

infected individual is more severe than if seek advice from an HIV expert in deter- only HBV has been contracted mining a testing sequence depending on the clinical setting prevention and treatment of HDV infection

is that of HBV it is appropriate to screen all past IDUs for HIV exposure, providing pre- and post-test

vaccination against HBV will prevent HDV counselling is provided susceptibility in the HBV immune individual Treatment of HIV HUMAN as HIV infection is uncommon in the IDU population in Australia it is recommended IMMUNODEFICIENCY VIRUS that if a positive test is obtained, advice be sought from a specialist clinician Fortunately in Australia the human immuno- treatment is available for prophylaxis fol- deficiency virus (HIV) positivity rate in IDUs lowing a positive exposure, for acute in- remains low, unlike the situation in many other fection, for chronic HIV infection and for countries (including the USA, Scotland and those who present with an AIDS defining Canada). The potential for increased rates of illness infection continues as does the need for sup- the course of HIV and AIDS has been radi- port of Needle Syringe Programs (NSPs) at cally improved with the advent of multiple all levels of our community. The Australian anti-HIV agents experience suggests that NSPs have been of great value in reducing the spread of HIV in the IDU community. Prevention advise of the risks of sexual and IDU- In Australia the HIV seroprevalence rate in related transmission IDUs is 1–2% compared to a rate of 5–10% in advise methadone maintenance as a homosexual/bisexual men. means of reducing IDU

Consider HIV exposure and acute infection in Effect of HIV IDUs complaining of: on IDU Problems Epstein-Barr virus (EBV) seronegative an active IDU should not be denied re- ‘glandular fever’ type symptoms sources for the investigation and treatment

flu-like symptoms out of season of HIV, HBV or HCV infections and their fever > 3 days complications

219 the risk of IDU linked bacterial infections will be increased in HIV positive IDUs. Consciously consider pneumonias, tuberculosis (TB), subacute bacterial endocarditis (increased mortality), and the well recognised pneumocystis, cryptococcal, candida and cryptosporidial infections Diseases HIV co-infection with either HBV or HCV worsens the prognosis of the liver disease always ensure adequate support if diag- Communicable nosis of HIV is made. Suicidal depression may follow diagnosis

HTLV/I/II

Infection with these retroviruses is less frequent in IDUs than is infection with HCV, HBV or HDV.

transmission occurs parenterally and sexually incidence of clinical disease is low with these infections no specific therapies are recommended

220 Chapter 19

Chapter 15

RESOURCES

Hepatitis C Council of New South Wales

www.hepatitisc.org.au/ other_resources/ other resources.htm Diseases Communicable

221 Diseases Communicable

222 Correctional Services Drug Issuesin Chapter 20 populations inotherstatesare: useamongprison levels ofinjectingdrug ofahistory Reported Health Survey in1996(Butler, 1997). The studyfound: Approximately 800inmatesinNSWwereassessedtheInmate AMONG PRISONERS PATTERNS OFDRUG USE E to 1,690per100,000(Australian InstituteofCriminology, 2000). adult population. For IndigenousAustralians, however, thisrateclimbs rate of120per100,000 representinganimprisonment prisoners, Census, therewere21,538 According tothe1999NationalPrison

date) for prisons inAustralia.date) for prisons There arenofederal andnonationalpolicy(norman- prisons ACH 46% inVictoria (Crofts etal., 1995) 36% inSouthAustralia(Gaughwin etal.,1991) half oftheinjectorshadinjectedinprison drug use 64% offemalesand40%maleshadahistoryinjecting entering prison 50% reporteddrinkingalcoholat‘harmful’levelspriorto 72% smokedtobacco Australian state and territory has its own prison system. has itsownprison Australian stateandterritory Chapter 15 223

Correctional Services Correctional

224 Services injected inprison1996 Needle SyringeProgrammaleandfemaleclientswhowereimprisoned Table 20–1 BORNE VIRAL INFECTIONS TRANSMISSION OFBLOOD PREVALENCE AND use whilstinprison. among thoseclientsthelevelofinjectingdrug Needle SyringeProgram(NSP)clientsand Table 20–1showsthenumberofimprisoned OF INJECTING AND PREVALENCE HISTORY OFIMPRISONMENT oainMales and Females Location TM=7 233 12 = 76 M NT C 92 46 22 35 =59 M 25 ACT 335 = M NSW I 0 830 64 18 7 =307 M =356 M VIC QLD NSW (Butleretal.,1997) male and66%amongfemaleinmatesin hepatitis Cprevalenceis33%among (NCHECR, 2001) atlessthanhalfapercent prisoners HIV infection remainslow amongAustralian Imprisoned (N) = 2 0 7 F= 27 = 2 0 4 F= 24 4 40 7 = 147 F 6 78 55 6 14 = 160 F = 216 F mrsndInjected % % Imprisoned

shows whichstateshavetheseprograms. doms andmethadoneprograms. Table 20–2 sion ofHIVandhepatitisCarebleach, con- Three interventionstopreventthetransmis- AND TRANSMISSION REDUCE RISKBEHAVIOUR INTERVENTIONS TO al., 1999) 4 casesofHIVtransmission(Dolanet Australian have prisons beenrecorded 1999; Postetal.,2001) hepatitis Ctransmission(Haberetal., NSW prisonshaverecorded5casesof (of those inprison) Implementation ofpreventionmeasuresinAustralianprisons(2002) Table 20–2 *Methadone isavailabletoremandees andinmateswhoarepregnant. found:prisons An evaluation ofthecondomprogram inNSW Condoms how effectiveitisagainsthepatitisC. decontaminate HIVfromsyringesitisunclear (Dolan etal.,1998,1999).Whilebleachcan were usingbleachtocleantheirsyringes found inmateshadeasyaccesstobleachand Two studiesoftheNSWbleachprogram Bleach Programs condoms (Lowe,1996) 52% ofthosehaving analsex always used obtainingcondoms 28% reported appropriate the locationofvending machineswas gram most inmateswereinfavourofthepro- S e i ipnesYsYes Methadone (MMT) Yes Yesvia dispensers Condoms Bleach NSW Jurisdiction C e nrqetYsNo No Yes No Yeson request No ACT Territory Northern Tasmania Victoria ot utai oN Yes No* No Yes No No South Australia Yes for general Western Australia Queensland Chapter 20 cleaning Yes for general cleaning cleaning Yes for general grams foundthattheywereacceptedbystaff (Rutter etal.,2001).Researchintothesepro- andSpain Germany programs inSwitzerland, Twenty exchange operatesyringe prisons in Prison Syringe ExchangeSchemes (24.3 vs.31.7per100personyears). hepatitis Cincidenceamongthetreatedgroup There was anon-significanttrendtoreduced (Dolanetal.,submitted). sis andself-report of heroinusewhenmeasuredby hairanaly- treated inmateshadsignificantlylower levels oftheprogramcontrolled trial found that mates inmethadonetreatment. Arandomised in 1986. In2001,therewere about1,000in- The NSWprisonmethadoneprogramstarted Maintenance Treatment Methadone oYesif onMMT at entry No oYesif onMMTat entry No* No Yes 225

Correctional Services Correctional Services 226 ates aneedleandsyringeprogram. were recorded. NoAustralianprisonoper- new casesofHIVorhepatitisCinfection decreased. Noassaultsoccurredandno prison andreportsofsyringesharing and inmates.Noinmatestartedinjectingin Dolan, K.&Wodak,A.1999,‘HIVtransmissioninaprisonsystemanAustralianState’, Dolan, K.,Mattick, R.P., Shearer, J., MacDonald,M.,Hall, W. & Wodak, A. (submitted), ‘A Crofts, N., Webb-Pullman, J. &Dolan,K. 1996, ‘An analysisoftrendsover timeinsocialand Gaughwin, M.D., Douglas, R.M. & Wodak, A.D. 1991, behaviours for‘Behind bars—risk HIV Dolan, K.,Wodak,A.&Hall,W.1998,‘AbleachprogramforinmatesinNSW:anHIVprevention Haber, P., Parsons, S., Harper, S., White, P., Robinson, W. &Lloyd, 1999, ‘A. Transmission of Butler, T.1997, Australian 2000, InstituteofCriminology REFERENCES NCHECR (NationalCentreinHIVEpidemiologyandClinical Research) 2001, Crofts, N.,Stewart,T.,Hearne,P.,PingX.Y.,Breskin,A.M.&Locarnini,S.A.1995,‘Spreadof Dolan, K.,Wodak,A.&Hall,W.1999,‘HIVriskbehaviourandpreventioninprison:ableach Butler, T.,Dolan,K.,Ferson,M.,McGuiness,L.,Brown,P.&Robertson1997,‘Hepatitis Lowe, D.1996, Australian prison’. randomized ofmethadonemaintenancetreatment vs. controlledtrial wait listcontrolinan behavioural factors inmates’, relatedtothetransmissionofHIVamongIDUsandprison no. 6975,pp. 285–88. transmission areview’ inprisons, in strategy’, hepatitis CwithinAustralianprisons’, J., S.A. Gerull andGaughwinM.D. (eds.), Australian InstituteofCriminology, Canberra. Medical Journal of Australia of Journal Medical Strategy HIV/AIDS National the of Evaluation bloodborne viruses among Australian prison entrants’. among Australian viruses prison bloodborne programme for inmatesinNSW’. B andCinNewSouthWalesprisons.Prevalenceriskfactors’, titis C and Sexually Transmissible Infections in Australia: Annual Surveillance Report Surveillance Annual Australia: in Infections Transmissible Sexually and C titis Population in the NSW Correctional System Correctional NSW the in Population Wales: Final Report for the Department of Corrective Services Corrective of Department the for Report Final Wales: Australia, 2001 , NCHECR,Sydney. vol.166,pp.127–130. Aust Evaluation of the condom trial in three Correctional Centres in New South New in Centres Correctional three in trial condom the of Evaluation Preliminary Findings from the NSW Inmate Health Survey of the Inmate the of Survey Health Inmate NSW the from Findings Preliminary ralian & New Zealand Zealand New & ralian Chapter 20 , vol.171,pp.14–17. HIV/AIDS and Prisons Conference Proceedings Conference Prisons and HIV/AIDS Drug and Alcohol Review Alcohol and Drug Journal of of Journal Australian Crime Facts and Figures and Facts Crime Australian Medical Journal of Australia, of Journal Medical , Technical Appendix4,AGPS, Canberra. , CorrectionsHealthService. Public Health Public British Medical Journal Medical British , vol. 18,no. 2,pp. 139–143. , vol.22,no.7,pp.838–840. , Sydney. vol.171,no.1,p.31. Medical Journal of Journal Medical HIV/AIDS, Hepa- HIV/AIDS, , Canberra. , vol. 310, Chapter 15 , Norberry, 227

Correctional Services Correctional

228 Services Rutter, S.,Dolan,K.,Wodak,A.&Heilpern,H.2001, Post, J.J.,Dolan,K.A.,Whybin,L.R.,Carter,I.W.J.,Haber,P.S.&LloydA.R.2001,‘Acute National Drug andAlcoholResearchCentre, Sydney.National Drug mission route’, infectionhepatitis Cvirus inanAustralian inmate: prison tattooingasapossible trans- Review of International Research and Program Development Program and Research International of Review Medical Journal of Australia of Journal Medical , vol.174,pp.183–184. Prison-based Syringe Exchange. A Exchange. Syringe Prison-based , Technical No. Report 112, As Patients Professionals Health Chapter 21 as adirectresultoftheirtreatingdoctor’s be at-risk There arerealandtragicexamples ofpatientsdying and even thelives ofpatientsundertheircaremay potentially effective healthcare. or or tea-roomconsultationswithcolleaguesarenotappropriate can develop aprofessional relationship. Self-treatmentandcorridor Note: AllhealthprofessionalsshouldhaveaGPwithwhom they astated bydrugoralcoholproblems. are allawareofhealthprofessionalswhoseownlives dev- H fessionals oralcoholproblems withdrug wherethewell The stakes areconsiderably higherinthecase of healthpro- may be exposed to particular risks relating to: may risks beexposed toparticular

warning signs reluctance ofcolleaguestoconfrontordealwithearly investigation) self-treatment (oftenfollowingself-diagnosis andself- easy accesstoprescriptiondrugs conflict betweentheirprofessionalandpersonallives fessional lives the demands,responsibilitiesandstressesoftheirpro- share withtherestofcommunity, healthprofessionals factors they oralcohol. fromthegeneralrisk drugs Apart EALTH professionals arenotimmunetoproblems with dependence . andwe being, 229

Health Professionals Health Professionals 230 you should: If you aretreatinganotherhealthprofessional DRUG ORALCOHOLPROBLEM A PROFESSIONAL WITH TREATING AHEALTH or NursingBoard suchastheMedical Board ing authority should seektheadviceoftheirregister- are notreceptive toyour advice, you the healthprofessional accordingly. Ifthey safety you may shouldadvise beatrisk, their work. Ifyou believe thatpatient consider theimpactoftheirproblem upon manager adequate after-carewithanongoingcare leave ituptothem. Ensureprovisionof be directive abouttheirfollow-up. Donot convenient itmay be their own medications, nomatterhow never orprocure allow themtoprescribe nothing that you give tootherpatients. Assume provide themwiththesameinformation health professional second stances, they areyour patientfirstanda treat any otherpatient. Inthese circum- treat theminthesameway thatyou would andshouldnevercrucial becircumvented physicaland appropriate examination are assess any otherpatient. Adetailedhistory assess theminthesameway thatyou would you would expect fromany otherpatient responsibility for theirmanagementthan their problem, orexpect themtotake more assume anything about theirknowledge of may beself-evident, but you shouldnot treat themasapatient,notcolleague. This present toyou for treatment persuasion) for ahealthprofessional to courage (andperhapssomenot-so-gentle recognise thatithastaken agreatdealof As ahealthprofessional,youshould: DRUG ORALCOHOLPROBLEM A COLLEAGUE WITH DEALING WITHA you have responsibility. astatutory nition of ‘impairment’ andfindoutwhether thedefi- inyour statetoclarify authority treated. Contacttherelevant registering thatthey areadequately and ensuring theirprogress practice whilemonitoring thehealthprofessional in supporting grams arenon-disciplinary, andaimedat tothepublic.potential risk These pro- alcohol problems andposeacurrentor ing withregistrantswhohave and drug Most have established programs for deal- ity ofanimpairedhealthprofessional. author- sponsibility tonotifyaregistering re- thereisastatutory some jurisdictions, responsibility for public protection. In arechargedwith authorities Registering " " " " " " problem.include: These you toa tional indicatorsthatmay alert to healthprofessionals. There areaddi- where inthishandbook,andapplyequally general indicatorsarediscussedelse- may have oralcoholproblem. adrug The tothepossibilitythatacolleague be alert Registering Authorities pain relief patients complainingofinadequate requirements; e.g.drugregister poor compliancewithdocumentation of illicitdrugs drug wastage,particularlyinthecase secretive manner administering patientmedicationina inappropriate prescribing unexplained behaviourchanges .Follow-up tomake surethatthey have taken 4. theirheadofdepartment Consideralerting 3. Ifyou feel able totalkthecolleagueyour- 2. Ifyoufeelunabletodealwiththematter 1. The Stepsto Take hear, having taken nopositive steps may tellyou whatthey thinkyou want to your advice. Beaware thatyour colleague or supervisor self, seriously until you aresurethatyou have beentaken your concerns. Donotletthematterdrop yourself, aware make your of supervisor reasons include: for theindividualandtheirpatients. The act, andtheconsequencescanbetragic ofreasonscolleaguesdonot a variety thatforelse does!Itisaregrettable truth take action,ormake surethatsomeone " " " " " " " " " " " " provide themwithcontactinformation ate specialist ask themtoconsultwithanappropri- ask fortheirversionofevents and why let themknowthatyouareconcerned arrange tomeetwiththemprivately cerned feeling intimidatedbythepersoncon- not knowingwhattodo unfounded fearoflegalaction action hoping thatsomeoneelsewilltake not wantingtocreatewaves return after-hours responsibilities; e.g. refusing to unwillingness torespondon-call pharmacy collecting patientmedicationsfromthe do not take on a treating role treating a on take not do Chapter 21 , but: note authority.their registering Pleaserefer tothe your advice, you shouldseektheadviceof of department. Ifthey arenotreceptive to theirhead professional accordinglyandalert may you shouldadvisethehealth beatrisk, their work. Ifyou believe thatpatientsafety Consider theimpactoftheirproblemupon may beingenuinedistress. assistancefor acolleaguewho concerned are actionsofprofessionalresponsibilityand Health Advisory Service. Health Advisory contacttheDoctors’ GPsupport appropriate andadvice.sional support Intheabsence of to Do nottry ‘go italone’. You willneedprofes- seek theirassistancesoonerratherthanlater. the firstinstanceandyou areencouragedto ate persontohelpyou withyour problems in ship withyour GPthenthey aretheappropri- If you have developed afunctionalrelation- personal andprofessional life. seek helpmay toyour befar moredetrimental Unfortunately, theconsequencesoffailing to sion ofpersonalorprofessionalinadequacy. You may feel thataskingfor helpisanadmis- that thisisrarely thecase. and manageyour problem. shows Experience edge andskillyou should beable tocontrol You may feel thatwith your professional knowl- of thecommunity. alcohol problems justlike any othermember Health professionals and may experiencedrug DRUG ORALCOHOLPROBLEM A PROFESSIONAL WITH BEING AHEALTH Registering Authorities Authorities Registering above. These 231

Health Professionals Health Professionals 232 Doctors’ HealthAdvisoryServices Table 21–1 ices gives contactdetailsfor eachstate. Table 21–1Doctors’HealthAdvisoryServ- toimpaireddoctors. vide a24-hourservice The Doctors’HealthAdvisoryServicespro- itra(03)9280 8722 (08)9321 3098 (03) 6223 2047 (08)8273 4111 (07)3833 4352 Western Australia Victoria Tasmania South Australia Queensland New SouthWales Contact: (03)94956011 problems.other drug includingalcoholand with healthconcerns toassistdoctorsandmedicalstudents service Program hasbeenestablished asafulltime In Victoria,theVictorianDoctorsHealth (after hours) (03) 6235 4165 (02) 9437 6552 Gambling Chapter 22 I Problem gambling Problem PROBLEM GAMBLING where inthisHandbook. its receptiveness ascovered ofintervention tosimilar forms else- prevalence, likelihood ofpresentationtohealthcareworkers and Problematic gambling isincludedherebecauseofitsincreasing (Orford, 2001). appetites—that arebasictolifewhichcangetoutofhand as appetitivebehaviours,thatisthedesiresorinclinations — across Australia. Collectively, such behaviours arereferred to iour andgambling. The latterisanareaofincreasing concern tors. Suchbehaviours includeeating,exercise, sexual behav- thatmay haveharms orantecedentfac- thesameunderlying

behaviours ofproblems thatexhibit and similarpatterns substances (i.e. thereisarangeof alcoholandotherdrugs) N ADDITION thatmayextendintothecommunity tofamilyandfriends totheindividual isgambling behaviour thatresultsinharm: to problems encounteredwithpsychoactive Chapter 15 233

Gambling Gambling 234 gambling may beaffecting his/her wellbeing. or more patients touseanddiscusswiththeirGP. Four Screen (seeFigure22–1)isausefultoolfor orscreeningtoolsthe teria ‘EIGHT’ Gambling While thereisnoconsensusondiagnosticcri- of problem gambling isdifficulttodetermine. have presentedfor helpandtheprevalence ofproblem gamblers Only asmallproportion Identifying Problem Gamblers demands oncommunityandpublic resources. one problem gambler. Inadditiontherearethe of upto10significantothersaffected by any affected by another’s gambling, withestimates andassociatesadverselyily members, friends Beyond thisarethemany thousandsoffam- ofdeveloping 1–3%atrisk aproblem. further gamblinglation experience problems witha It isgenerallyacceptedthat2%ofthepopu- the number ofpeoplewhotake part. for legalgambling increase, sodo portunities tels andclubs. Itiswellknown thatastheop- of electronicgamingmachinesintolocalho- casinos andmorerecentlyby theintroduction availability oflegalgambling facilities, firstlyby have legislatedtoallow majorincreasesinthe Over thepast20years Australian governments The harmmayinclude: sion andsuicidalthoughts health problems includinganxiety, depres- breakdown ofrelationships activity criminal loss ofemployment financial loss—even bankruptcy yes yes answers suggestthatthepatient’s PROBLEM GAMBLERS PRESENTATION OF more comfortabletodisclosethattheirgam- If framedasahealthissue,patientsmayfeel to askgenerally: ofthecomplaintitmay beappropriate history done inanumberofways. a While gathering Broaching thesubjectofgambling canbe commonly presenttoGPswith: guilt. Studieshave shown thatgamblers will ormaycerns, minimisetheconnectionoutof their gambling and their currenthealthcon- Patients may notseeaconnection between psychological disordersandnoted: comorbidity ofproblem gambling withother Research hasexaminedtheratesof ‘How are you spending your leisure time?’ leisure your spending you are ‘How back andneck pains indigestion problemsheavy alcoholuseor otherdrug sleep difficulties headaches anxiety depression drug andalcoholproblems drug anxiety disorders bipolar disorder pressive disorders high ratesofcomorbiditywithmajorde- Developed bySeanSullivan, GoodfellowUnit,AucklandMedicalSchool(unpub.) Source: EIGHT GamblingScreen Figure 22–1 .Ihave towinmoney topay tried debts. 8. Ihave aboutmy received gambling criticism inthepast. 7. togambling towinback OftenIgettheurgetoreturn lossesfromapastsession. 6. Ioftenfindthatwhenstopgambling outofmoney. I’ve run 5. SometimesI’ve found itbetternottotellothers, especiallymy family, abouttheamount 4. WhenIthinkaboutit,gambling hassometimescausedmeproblems. 3. SometimesI’ve felt guiltabouttheway Igamble. 2. SometimesI’ve felt depressedoranxiousafterasessionofgambling. 1. of timeormoney Ispend gambling. " " " " " " " " " " " " " " " " Early Intervention Gambling Health Test Test Health Gambling Intervention Early No, Ihaven’t. Yes, that’s true. No, Ihaven’t. Yes, that’s true. No, thatisn’tso. Yes, that’s so. No, thatisn’tso. Yes, that’s so. No, Ihaven’t. Yes, that’s true. No, thatisn’tso. Yes, that’s so. No, thatisn’tso. Yes, that’s so. No, Ihaven’t. Yes, that’s true. Chapter 22 (no date) 235

Gambling Gambling 236 low-up theirprogressatthenext plannedvisit. they canhelpreducethe urgetogamble. Fol- or considerprescribingantidepressantsas and/ for themtoattendoneoftheseservices make anappointment be causingsomeharm If apatientrecognisesthattheirgambling may lem gamblers and/or their families including: toprob- offer avariety ofcounsellingservices through agenciessuchasBreakEven. They Most statesoffer freeface-to-face counselling negative outcomesfromtheirgambling. thepositive and Ask patientstodescribe Indicate thatgambling problems can: Discuss how: OPTIONS TREATMENT/REFERRAL be thecauseoftrouble. that someoneelse’sgamblingproblemmay as relationshipandfinancialdifficulties.Or bling iscausingthempersonalproblemssuch relationship counselling financial counselling personal counselling affect physical andemotionalhealth cause depressionandanxiety cause stress industry winnersarethegambling the onlytrue tally random winning inmany ofgambling forms is to- losing isthemostprobable outcome gambler haslittleornocontrol gambling isasystemover whichthe Orford, J.2001, REFERENCES Wiley &Sons,Chichester. Excessive Appetites. A Psychological View of Addictions of View Psychological A Appetites. Excessive Chapter 22 , 2 nd edn.,John 237

Gambling Gambling 238 Part 5

Appendices & Glossary

239 241 Appendices

NHMRC ALCOHOL GUIDELINES – SHORT- AND LONG-TERM RISK

Table A–1 Risk of harm in the short term

Low Risk Risky High Risk

minimal risk, regularly drinking sustaining potential health benefits to intoxication moderate to high levels of drinking over time Appendix A

Males up to 6 standard drinks 7–10 standard 11 or more (on any one day) on any one day, no more drinks on any standard drinks on than 3 days per week one day any one day

Females up to 4 standard drinks 5–6 standard 7 or more standard (on any one day) on any one day, no more drinks on any drinks on any one than 3 days per week one day day

HIGH RISK OF HARM FROM INTOXICATION

Source: NHMRC (National Health and Medical Research Council) 2001, Australian Alcohol Guidelines: Health risks and benefits, National Health and Medical Research Council, Canberra.

Table A–2 Risk of harm in the long term

Low Risk Risky High Risk

minimal risk, regularly drinking to sustaining moderate potential health benefits intoxication to high levels of drinking over time

Males up to 4 standard drinks 5–6 standard drinks 7 or more standard (on an average day) per day per day drinks on any one day

Males up to 28 standard drinks 29–42 standard 43 or more standard (overall weekly level) per week drinks per week drinks per week

HAZARDOUS HARMFUL

Females up to 2 standard drinks 3–4 standard drinks 5 or more standard (on an average day) per day on any one day drinks on any one day

Females up to 14 standard drinks 15–28 standard 29 or more standard (overall weekly level) per week drinks per week drinks per week

HAZARDOUS HARMFUL

Source: NHMRC (National Health and Medical Research Council) 2001, Australian Alcohol Guidelines: Health risks and benefits, National Health and Medical Research Council, Canberra.

241 Appendix A

242 Appendices

LABORATORY MARKERS FOR ALCOHOL-RELATED DAMAGE

Test Advantages Disadvantages (GGT) Serum • non-specific indicator of • low sensitivity — GGT Gamma-Glutamyl liver disease may be elevated by Transferase medications, non- • sensitivity 20–50% for alcoholic liver disease, consumption of 40g alcohol (enzyme in liver, diabetes, obesity. per day or more blood and brain) A standard measure • raised before AST and ALT of liver function • has half-life of 14–26 days AST/SGOT • reflects overall liver health • like GGT, elevation in (Aspartate one of these measures • can be routinely obtained alone may not aminoTransferase) using standard laboratory necessarily be due to measures ALT/SGPT alcohol consumption Alanine aminoTransferase Appendix B

(CDT) • sensitivity is 60–70%; • need to exclude Carbohydrate specificity 95% uncommon liver Deficient (few false positives) disease e.g. primary biliary cirrhosis Transferrin • elevated levels specifically (variant of the associated with the (note: this test is not protein that metabolism of alcohol and routinely available in transports iron) dependent on quantity clinical practice) consumed (detected at > 60g per day) • returns to normal on reduction of consumption (half-life of 15 days) (MCV) Mean red • supportive diagnostic tool • less sensitive than GGT Cell Volume when used with LFTs – can be elevated by medications e.g. valproate, azathioprine, folate and Vit B 12 deficiency, liver disease, hypothyroidism, smoking Other laboratory measures Thrombocytopaenia, elevated bilirubin, low albumin and a prolonged INR all indicate significant organ damage related to high alcohol intake (Dawe et al., 2002).

243 Appendix B 244 Dawe, S.,Loxton,N.J.,Hides,L.,Kavanagh,D.J.&Mattick,R.P.2002, REFERENCES 2 Screening Instruments for Alcohol and Other Drug Use and Other Psychiatric Disorders Psychiatric Other and Use Drug Other and Alcohol for Instruments Screening nd edn.,CommonwealthDepartmentofHealthandAgeing,Canberra. Review of Diagnostic of Review , The AlcoholUseDisorders Identification Test: Interview Version AUDIT –INTERVIEW VERSION Source: Babor,T.,Higgins-Biddle, J.C.,Saunders,J.&Monteiro,M.G.2001, appsocsci/audit/DRUGS. Mental HealthandSubstanceDependence, Geneva,www.stir.ac.uk/departments/humansciences/ ders Identification Test (AUDIT): Guidelines for Use in Primary Care Primary in Use for Guidelines (AUDIT): Test Identification ders 1. How oftendo How a you have drink containing 1. 5. How oftenduring How the last haveyear you failed to 5. oftenduring How the last haveyear you found 4. oftendo How you have six or drinks more onone 3. drinks many containing How alcohol do have you 2. (4) Daily or almost Daily daily Weekly (4) Monthly (3) Less than monthly (2) Never (1) (0) of drinking?because wasdo what normally expected from you or almost Daily daily Weekly (4) Monthly (3) Less than monthly (2) Never (1) (0) had started? that not were you able to stop drinking once you for Questions 2and 3= 0 toSkip Questions 9and 10if Total Score or almost Daily daily Weekly (4) Monthly (3) Less than monthly (2) Never (1) (0) occasion? 10 or more 7,8or 9 (4) or6 5 (3) or4 3 (2) or2 1 (1) (0) on atypical day are when you drinking? a week times more or 4 to3 2 aweek times (4) to4 2 a times month (3) or Monthly less (2) [skip Never to questions 9–10] (1) (0) alcohol? If total is greater cut-off,than recommended consult User’s Manual Appendices Record totalRecord of specific items here arelative Has or friend or adoctor or another 10. else or you been injured Have someone asa 9. oftenduring How the last haveyear you been 8. oftenduring How the last haveyear you had 7. oftenduring How the last haveyear you 6. (4) Yes, during Yes, the last year but Yes, not in the last year (4) No (2) (0) down? cutor you drinking suggested health worker been concerned about your during Yes, the last year but Yes, not in the last year (4) No (2) (0) result of your drinking? oralmost Daily daily Weekly (4) Monthly (3) than Less monthly (2) Never (1) (0) before hadbeendrinking? because you unable toremember whathappened the night oralmost Daily daily Weekly (4) Monthly (3) than Less monthly (2) Never (1) (0) a feeling of guilt or after remorse drinking? or almost Daily daily Weekly (4) Monthly (3) Less than monthly (2) Never (1) (0) yourself goingafter a drinking heavy session? needed afirst drink in the morning to get (2 nd edn.)WHO,Departmentof The Alcohol Use Disor- Use Alcohol The 245

Appendix C Appendix C 246 The Questionnaireappearsoverleaf. Then addallnumbersinthatcolumntoobtainthetotalscore. column. number associatedwitheachanswer theappropriate Write inthecolumnatright. instructions: Eachresponseisscoredusingthenumbersattopofeach Scoring AUDIT –SELF-REPORT VERSION Appendices 247

Appendix D Appendix D 248 answers willremainconfidentialsopleasebehonest. and treatments,itisimportantthatweasksomequestionsaboutyouruseofalcohol.Your GP: Becausealcoholusecanaffectyourhealthandinterferewithcertainmedications The AlcoholUseDisordersIdentificationTest:Self-reportVersion humansciences/appsocsci/audit/DRUGS, pp.30-31. Department ofMentalHealthand SubstanceDependence,Geneva,www.stir.ac.uk/departments/ Source: Babor,T.,Higgins-Biddle, J.C.,Saunders,J.&Monteiro,M.G.2001, Disorders Identification Test (AUDIT): Guidelines for Use in Primary Care Primary in Use for Guidelines (AUDIT): Test Identification Disorders .How manydrinks containing 2. .Have youor someone else 9. Howoften during the last year 8. Howoften during the last year 7. Howoften during the last year 6. Howoften during the last year 5. Howoften during the last year 4. Howoften doyou have six or 3. 10. Has arelative, Has friend, doctor 10. .Howoften doyou have adrink 1. drinking? typical day when you are alcohol doyouhave on a drinking? been injured because of your been drinking? night before because you had remember what happened the have you been unable to or remorse after drinking? have you hadafeeling of guilt session? going after aheavydrinking in the morning to get yourself have you needed afirst drink because of drinking? normallywas expected of you have you failed to do what you had started? not able to stop drinking once have you found that you were more drinks onone occasion? down? drinking or suggested you cut been concerned about your or other health care worker containing alcohol? usin 4 3 2 1 0 Questions r23o r67t 10or more 7to 9 5or 6 3or 4 1 or 2 never lessthan never never never never never never oyes, but no no less than less than less than less than less than monthly monthly monthly monthly monthly monthly monthly or less not in the in not not in the in not last year last year otl weekly daily or monthly weekly monthly weekly monthly weekly monthly weekly monthly weekly monthly yes, but times a month 2–4 times a week 2–3 the last year the last year almost daily almost daily almost daily almost daily almost daily almost daily yes, during yes, during 4 or more times a daily or daily or daily or daily or daily or Total week (2 The Alcohol Use Alcohol The nd edn.)WHO, TIP SHEETFORREDUCINGALCOHOLCONSUMPTION Source: adaptedfromWAADA,1995;NSWHealth,2000

Ensure youhaveenoughfoodtoeat,andtaximoneyget home. Limit thenumberofdrinksandmoneyforeachdrinkingoccasion. Avoid saltysnacks,nomatterhowtempting. This makesiteasiertocountyourdrinks. Drink afullglasseachtimeandsaynototop-ups. Plan yourdrinkingtime—beginlaterandgohomeearlier. then on. Alternatively, buythefirstroundthenoptoutandyourowndrinksfrom Avoid drinkinginrounds,orkeepingupwithyourmates. Eat when,orbeforeyoudrinkasithelpstoslowdowntherateofabsorption. for yourselfandyourfriends. Ensure thereareplentyofnon-alcoholorlow-alcoholdrinksavailable If thirsty,quenchthirstwithwater,thenhaveanalcoholicdrink. Alternate alcoholicdrinkswithnon-alcoholicspacers. Drink slowly,andconcentrateoneachmouthful. Place glassonthetablebetweeneachsip. Drink slowly,sip,don’tgulp,takesmallermouthfuls. Appendices 249

Appendix E Appendix E 250 WAADA 1995, NSW Health2000, REFERENCES www.health.nsw.gov.au. Services Council(DASC),Adelaide. Clinical Guidelines 2000–2003 Guidelines Clinical The Drinker’s Guide to Cutting Down or Cutting Out Cutting or Down Cutting to Guide Drinker’s The Alcohol and Other Drugs Nursing Policy for Nursing Practice in NSW: in Practice Nursing for Policy Nursing Drugs Other and Alcohol , NSWHealthDepartment,Gladesville,NSW, , DrugandAlcohol Appendices

ALCOHOL WITHDRAWAL ASSESSMENT SCALE (CIWA–AR)

Nausea and vomiting Tactile disturbances Ask ‘Do you feel sick in the stomach? Ask ‘Have you any itching, pins and Have you vomited?’ Observation: needles sensations, any burning, any numbness or do you feel bugs crawling (0) No nausea and no vomiting on or under your skin?’ Observation: (1) Mild nausea with vomiting

(2) (0) None Appendix F (3) (1) Very mild itching, pins and needles, (4) Intermittent nausea, with dry burning or numbness retching (2) Mild itching, pins and needles, (5) burning or numbness (6) (3) Moderate itching, pins and needles, (7) Constant nausea, frequent dry burning or numbness retching and vomiting (4) Moderately severe hallucinations (5) Severe hallucinations (6) Extremely severe hallucinations (7) Continuous hallucinations Tremor Auditory disturbances Arms extended, elbows slightly flexed Ask ‘Are you more aware of sounds and fingers spread. Observation: around you? Are they harsh? Do they frighten you? Are you hearing anything (0) No tremor that is disturbing to you? Are you (1) Not visible, but can be felt fingertip hearing things you know are not there?’ to fingertip Observation: (2) (3) (0) Not present (4) Moderate (1) Very mild sensitivity (5) (2) Mild sensitivity (6) (3) Moderate sensitivity (7) Severe, even with arms not (4) Moderately severe hallucinations extended (5) Severe hallucinations (6) Extremely severe hallucinations (7) Continuous hallucinations Paroxysmal sweats Visual disturbances Observation: Ask ‘Does the light appear to be too bright? Is its colour different? Does it (0) No sweat visible hurt your eyes? Are you seeing things (1) Barely perceptible sweating, palms you know are not there?’ Observation: moist (2) (0) Not present (3) (1) Very mild sensitivity (4) Beads of sweat obvious on (2) Mild sensitivity forehead (3) Moderate sensitivity (5) (4) Moderately severe hallucinations (6) (5) Severe hallucinations (7) Drenching sweats (6) Extremely severe hallucinations (7) Continuous hallucinations

continued over page

251 ALCOHOL WITHDRAWAL ASSESSMENT SCALE (CIWA–AR) (CONTINUED)

Anxiety Headache, fullness in the head Ask ‘Do you feel nervous?’ Ask ‘Does your head feel different? Observation: Does it feel as though there is a band around your head?’ Do not rate for (0) No anxiety, at ease dizziness or light headedness.

Appendix F (1) Mildly anxious Otherwise rate severity. (2) (3) (0) Not present (4) Moderately anxious or guarded so (1) Very mild anxiety is inferred (2) Mild (5) (3) Moderate (6) (4) Moderately severe (7) Equivalent to acute panic states (5) Severe as seen in severe delirium or acute (6) Very severe schizophrenic reactions (7) Extremely severe Agitation Orientation and clouding of sensorium Observation: Ask ‘What day is this? Where are you? (0) Normal activity Who am I?’ Observation: (1) Somewhat more than normal activity (0) Oriented and can do serial (2) additions (3) Ask person to perform serial (4) Moderately fidgety and restless addition of 3s up to 30 (5) e.g. 3, 6, 9… (6) (1) Cannot do serial addition or is (7) Paces back and forth during most uncertain about date of the interview or constantly (2) Disoriented for date by no more thrashes about than 2 calendar days (3) Disoriented for date by more than 2 calendar days (4) Disoriented for place and/or person

252 Observations ALCOHOL WITHDRAWALOBSERVATIONCHART Nursing Management: unm is aeAge Firstname Surname Blood pressure Respiration rate Pulse Temperature (per axilla) Blood glucosereading Breath alcohol reading Total score sensorium Orientation andcloudingof Headache, fullnesshead in disturbances Visual Auditory disturbances Tactile disturbances Agitation Anxiety Paroxysmal sweats Tremor Nausea and vomiting Alcohol Withdrawal Assessment Score Ensure adequatehydration Re-orientate thepersonifconfused Provide reassuranceandexplanation Nurse inaquiet,evenlylitenvironment Appendices Time Date 253

Appendix G Appendix G 254

Vitamin Administration General Combined AlcoholandBenzodiazepineWithdrawal Withdrawal ConvulsionProphylaxis When significantwithdrawalispredictedpreferreddrugtreatmentis: Medical ManagementofAcuteAlcoholWithdrawal

10 mgperdayoveraperiodof7–14days. such regimesfeatureQIDdosesofdiazepamwiththetotal dailydosedecreasingby5– mine topreventacuteWernicke’sSyndrome. persons receivingintravenousdextroseorglucoseshouldfirstreceiveparenteralthia- Wernicke’s Syndrome) give thiamineorallyunlessparenteraladministrationindicated(e.g.malnutrition,acute thiamine 100mgandmultivitaminsdaily vomiting) maybeuseful symptomatic treatment(e.g. paracetamol forheadache,metoclopramidenauseaor withdrawal regimeinaccordancewiththerecommended guidelines (see during subsequentdays,inpatientclientswillrequireacontinuous, gradualdiazepem 20 mgper2hoursuntilthescorehassettled drawal symptomsortopreventwithdrawalconvulsions.This shouldbegivenatarateof in theinitialstages,morediazepammayberequiredto manageacutealcoholwith- until thetotalfirstdaydosehasbeengiven intake, toamaximumof80mg.Thisdoseshouldbegiven at arateof20mgper2hours of diazepamgivenduringDay0shouldbeequivalenttothe stated doseofbenzodiazepine where acombinedalcoholandbenzodiazepinedependenceexists,theminimumdose preferred drugtreatmentis: assessment if AWSscorerisesto15ormorerecommencediazepamloadingafterfurthermedical further medicalassessmentisrequiredfordosesbeyond120mg hourly untilAlcoholWithdrawalScale(AWS)scoreis10orless weight 75–90kg;total100mgif>90kg).Thereafterdiazepam20orallyby2 diazepam 20mgorally2hourlybyweight(i.e.total60if<75kg;80 has beengivenonDay0unlessthepatientisexcessivelydrowsy. ued 2hourlyuntilthescoreis10orless.Ensurethataminimumtotalof75mgdiazepam Note: IfhighAWSscoresoccurduringtheDay0loadingphase,dosesshouldbecontin- " " " Drugs: Hospital Management of Intoxication & Withdrawal & Intoxication of Management Hospital Drugs: a diazepam5mgorallyb.d. diazepam10mgorallyb.d. Day 3 Day 1, 2 Day 0 (i.e. if<75kg,additional15mg2hoursafterlastdose) diazepam byweightrelatedloadingtoaminimumof75mg ) Guidelines II: Guidelines Intervention Level: Brief; Moderate (Mod.); Intensive (Intens.) Intensive (Mod.); Moderate Brief; Level: Intervention THE FIVE‘A’s nes Systematically Intens. o.Explore Mod. o neetdi utigItrse nQitn Recently Quit “Howdoyou Interested inQuitting Brief Not Interested in Quitting Which of these best describes you? mkrThinking of quitting Smoker xsoe Quit formore than 6months Never smoked Quit in the last 6months Ex-smoker Not thinking of quitting Ex-smoker Smoker balance. decisional and dislikes; e.g. explore likes about quitting. the hardest thing what would be difficulties and quitting?” considered “Have you now?” smoking right feel aboutyour Appendices nes Assess high-risk Intens. o.Experience from Mod. re “How important Brief 2. Assess situations. dependence. Assess nicotine scale 1–10). confidence (use motivation and Explore “What didn’t?” “What worked?” attempts: past quit you right now?” is quitting for 1. Ask nes Explore high-risk Intens. o.Check how they Mod. re “Any slips, even Brief situations. problems?” “Any benefits or are managing. one puff?” 255

Appendix H Appendix H 256 Intens. Mod./ o neetdi utigItrse nQitn Recently Quit State Interested inQuitting Brief Not Interested in Quitting effects. adverse health objective feedback on any personalised Provide reactivity. choose, handle their right to acknowledge quitting and considering importance of Intens. Mod./ re Setquit date. Brief 3. Advise help?” “How can I you back?” “What tipped work?” “What didn’t worked?” “What has solutions: Brainstorm to quit. Support decision Intens. Mod./ re Affirm decision: Brief to date. benefits accrued Summarise health.” do for your that youcould important thing the most “That’s great, it’s nes Discuss options Intens. o.Mention Mod. o neetdi utigItrse nQitn Recently Quit Express interest: Interested inQuitting Brief Not Interested in Quitting attempts toquit. take 5–6 most smokers difficulties, Acknowledge card. and Quitline Quitbook Offer (NRT, Zyban). Pharmacotherapy e.g. Quitline, Quitline card. Quitbook and you need it.” you need here to help if health and I’m termyour long “I’m interested in Appendices Intens. Mod./ re Offer Quitbook Brief 4. Assist monitoring. effects, dosage, type, side Zyban, covering e.g. NRT, pharmacotherapy Discuss social situations. emotions and negative support, habit, triggers, social withdrawal, with nicotine Review dealing and quit date. Develop a plan Card. and Quitline nes Help with Intens. o.Express ongoing Mod. re Offer support Brief risk situations. Assist with high- and stress. negative moods, withdrawal, e.g. weight gain, situations specific along.” are getting to see how you “I’ll make a note interest: Card. and Quitline e.g. Quitbook 257

Appendix H Appendix H 258 o.Md Enlist supports; Mod. Mod. nes Offer Intens. o neetdi utigItrse nQitn Recently Quit Offer help in Interested inQuitting Brief Not Interested in Quitting can help. explain how you appointment and future. nes Discuss aplan Intens. re Suggest follow- Brief 5. Arrange e.g. Quitline. program. 12 week support Discuss Quitline appointments. up value of follow- highlighting the days. next seven ideally inthe up appointment, Mod. Intens. re Offer follow-up Brief relapse. occurrence) of likelihood (or a there is appointment if CREATE CC RR EE AA TT EE responsibilities? incentives, benefits greater than costs e.g. reminder systems? resources and time? interested in quitting? routine practice? argeted — can all smokers be identified especially those who are ffective —are evidence based strategies for implementation being used fficient — what steps have been taken tomake the process a part of oordinated — is there a clear plan, identified role and allocated eceptive —what will stimulate interest in doing this e.g. feedback, bility —is there adequate knowledge, appropriate skills, sufficient Appendices 259

Appendix I Appendix I 260 PROFORMA FORDECISION BALANCE WORKSHEET Quit Smoke Appendices ie(eei)Dislike (cost) Like (benefit) 261

Appendix J Appendix J 262 HEPATITIS CREFERRALCHECKLIST Source: NorthernRiversArea Health Service ae To Doctor: Date: / / Patient Details Patient Referring Medical Officer Signature: Comments: The followinglaboratory results accompany this referral: Date of Birth: Provider No: Provider FBC Prothrombin Time LFTs ALT (3abnormal results over 6months) HCV Antibody (confirmed +ve) Past Liver Biopsy results EUC Fe studies HIV Ab HAV IgG HbsAg HBV serology including TSH Alpha feto protein baseline Address: Surgery: Name: Name: Appendices HbcAb HbsAb 263

Appendix K Appendix K 264 aversion therapy AUDIT assessment anticraving agents antagonist ANCD amphetamines alcohol agonist administration –routesof ADIS ADIN addiction addict abstinence syndrome abstinence AA A QUICK LISTING to healthprofessionals. on theAODsectorwithemphasisthoseconceptsandtermsthatmaybeofspecificinterest This hasbeencompiledfromanumberofAustralianandinternationalsources.Itisfocussed A TOZDRUGGLOSSARY buprenorphine brief motivationalinterviewing brief intervention brain function binge benzodiazepines behaviour change barbiturates B Glossary Evidence BasedPractice(EBP) efficacy effectiveness education (schools) education (patientfocus) education (communityfocus) ‘E’ orecstasy E drug states drug-related behavioursandharms drug interactions drug abuse ‘doctor shopping’ detox/detoxification depressants dependence –DSM–IV&ICD–10 D cravings classes ofpsychoactivedrugs controlled use comorbidity ordualdiagnosis communication style Cochrane Library cocaine chroming CDSR CBT cannabis C FRAMES follow-up FLAGS F 265

Glossary Glossary 266 overdose opioids/opiates O neurotransmitters neuro-adaptation NEPOD National DrugStrategyHouseholdSurvey National DrugStrategy(NDS) N mesolimbic dopaminesystem/reward motivational interviewing models ofdruguse methadone maintenance pharmacotherapy maintenance M licit drugs lapse/lapse-relapse cycle LAAM L ketamines K intoxication interventions inhalants illicit drugs I harm reduction harm minimisation hallucinogens half-life H gold standards GHB GABA G (NDSHS) centre ofthebrain risk/ ‘atrisk’groups relapse/relapse prevention R psychoactive drugs prevention –primary,secondary&tertiary pregnancy anddrugs polydrug use pharmacotherapies patterns ofdruguse patient information patient-centred approach party drugs P zero tolerance Z youth Y withdrawal syndrome W unsanctioned druguse U treatment options/modalities tolerance Therapeutic Community(TC) THC T supply reduction street language/names stimulants stages ofchange social rehabilitation shared care setting limits serotonin screening tools salience S their druguse;she/heusesdrugs. son’s patternofAODuse(i.e.highrisk,lowrisk).Alternatives:he/shehasproblemsrelatedto stereotypes orlabelsaperson.‘Addict’doesn’tprovideusefulinformationregardingper- A termarisingfromthediseasemodelofaddiction.Generallyconsideredjudgmentalasit addict See abstinence syndrome Refraining fromusingdrugs. abstinence religion butisspirituallybased. active involvementandregularattendanceatmeetings.AAisnotaffiliatedwithanyparticular abstinence asagoal.Abstinenceisachievedbycommitmentto12-stepprogram,requiring A AA A GLOSSARY conference events,latestpublicationsandlinkstoAODservices. and individualstosearchsharerelevantinformationon licitandillicitdrugissues.Infoon ADIN’s largecollectionofqualityassessedwebsitesand databases enablesorganisations ‘Tough onDrugs’ ian GovernmentDepartmentofHealthandAgeingunderthe NationalIllicitDrugStrategy– provided byprominentAustralianandinternationalorganisations. ItisfundedbytheAustral- This providesacentralpointofaccesstoqualityInternet-basedalcoholanddruginformation A ADIN logical andphysicaldependence. of addictionisprogressiveandchronic.Addictionmorecommonlyreferredtoaspsycho- Physical andpsychologicalcravingforadrugordrugsrelatedbehaviours.Theprocess addiction lcoholics ustralian withdrawal syndrome D www.adin.com.au A nonymous isavoluntary,anonymousself-helporganisationwhichpromotes rug I nformation Glossary N etwork 267

Glossary Glossary 268 Alcohol iscommonlycalled administration –routesof as the opportunities forintervention.Screeningtoolsalcoholuse, canbeself-administered,such use assistsGPstoidentifyalcohol-relatedharmsorrisky patterns ofdrinkingandprovides mortality andhealthcarecostsfromdrugs.Routinelyasking aboutpatternsofalcohol(&OD) ingredient inalcoholicbeverages.Alcoholissecondtotobacco initseffectonmorbidity, Classified asasedative/hypnoticdrug.Ethanol(ethylalcohol C alcohol See also effect dependsuponthedrug’saffinityforreceptorsite anditsconcentrationatthesite. CNS periphery(endogenousagonists).Agonistsbindtoandactivatereceptorsites.Their A drugthat‘mimics’naturallyoccurringchemicalswhichstimulatereceptorsinthebrainand agonist and quitting.Methodsofadministrationincludeoral,nasal,smoked,rectalinjected. harms. Changingfromoneroutetoanothermaybeausefulsteppingstonecuttingdown body willaffecthowquicklythedrughasaneffect,ismetabolisedandpotential 08 9442 5000 (Perth) Important informationwhentakingapatienthistorysincethewaydrug(ordrugs)enters WA 13 15 70 VIC 0732362414(Brisbane) QLD 1300131340(Adelaide) 0889818030(Darwin) 994 811 1800 SA TAS NT 0293618000(Sydney) NSW 0262054545 ACT matters; e.g.withdrawalandmaintenancetherapies.Generallyoperatea24-hourservice. families andcarers.Somestatesofferaccesstoexperiencedcliniciansonspecificclinical include printedinformationforpeopleexperiencingAODrelatedharms,andtheirfriends, Each stateprovidesAODassessment,referraloradvisory/counsellingservices.Resources A ADIS lcohol and AUDIT AUDIT 801783(L)1800 198 024 (WA) 1800 177833(QLD) 1800 629683(NT) 1800 422599(NSW) antagonist, antagonist, D have goodreliabilityandvalidity. rug I nformation pharmacotherapies grog, piss grog, S ervices and booze. 1800 198024(WA) 2 H 5 OH) isthemain psychoactive sure, sweating,chills,lossofappetite,nauseaorvomiting. energy. Othereffectsmayincludedilationofthepupils,tachycardia,elevatedbloodpres- drugs; e.g.Ritalin.Effectsincludewakefulness,perceivedincreasesinawarenessandgreater xmls Acamprosate[Campral]suppresses alcoholcravingbyfacilitating Examples: Pharmacotherapeutic medicationsthatreducecravingfora drug,thuspromotingabstinence. anticraving agents See also opioid agonist. Examples: naltrexoneatopioidreceptors;buprenorphine,anantagonistandapartial but inhibitingtheactionsofagonistsforthatreceptor A drugthatcanbindwithareceptorsiteinthebrain,producingnopharmacologicalresponse antagonist to AODrelatedsites. cluding evidencesupportingtreatment,fundingopportunities,druguseinformationandlinks The ANCDwebsitecontainsinformationaboutnationalprojects,researchpublicationsin- organisations andlawenforcement,education,healthsocialwelfareinterests. Drug Strategy(MCDS).ANCDhasbroadrepresentationfromvolunteerandcommunity Key advisorybodyestablishedbythePrimeMinisterthatsupportsMinisterialCouncilon A ice. fast, ANCD quick, pills, pep uppers, dexies, Commonly called methamphetamine (speed,crystal,meth,ice)aswell A categoryofCNSstimulantsthatincludeamphetamine(commonlyknownas‘speed’), amphetamines See also mission andreducingglutamatesothatabalanceisrestored. ated with use include aggression, agitation and impaired judgement. Chronic use can result can use Chronic judgement. impaired and agitation aggression, include use with ated in permanent personality and behavioural changes (WHO, 1994). (WHO, changes behavioural and personality permanent in ustralian agonist, pharmacotherapies www.ancd.org.au N ational go-ey, speed, go-fast, crystal, amphetts, ox blood ox amphetts, crystal, go-fast, speed, go-ey, pharmacotherapies C ouncil on Glossary D rugs d Exaggerated behaviours associ- behaviours Exaggerated -amphetamine andprescription (mixedwithiodine), GABA GABA trans- 269

Glossary Glossary 270 Examples: AOD problemsincludes: duration ofeffects. anti-epileptics andmusclerelaxants.Theyareclassifiedaccording tospeedofonsetand Introduced assaferalternativestobarbiturates.Theyareused asanti-anxietymedications, benzodiazepines See also ceived abilitytoadoptthenewbehaviour. the behaviour,exposuretobehaviour(weighingup prosandcons)theper- beliefs andpriorknowledgeofthebehaviour,attitudes subjectivenormssurrounding A responsetoaspecificbehaviour(adoption/quitting).Behaviour changeisinfluencedby behaviour change produces progressiveCNSdepression,rangingfrommildsedationtoanaesthesia. A sedative–hypnoticgroupofdrugsthatarenowrarelyseeninAustralia.Increasingdosage barbiturates B related behavioursothatthepatientisunwillingtocontinuecertainbehaviours. Therapy basedontheuseofaversivestimuli,suchaselectricalshocklinkedwithdrug aversion therapy A AUDIT the useofappropriate Taking agoodhistory,opportunisticcommunication,observationsandinvestigations assessment See also approximately 2-5minutestocomplete.SeeAppendicesC&D. weeks). tolerance, of presence with especially dose, lethal and therapeutic between margin narrow hence dangerous in overdose. in dangerous hence lcohol sation). create opportunitiesforharmreduction(injectingbehaviour,sexualimmuni- gate abnormalitiesand/orscreenforillnessespredisposedbythedrugsused. physical examinationandwhereneededlaboratoryteststoconfirmdruguse/investi- tors, history ofdruguseandtreatment,medicalpsychiatricproblems,psychosocialfac- Commonlycalled U stages of change stages ofchange screening tools se D Valium, Librium, Halcion, Xanax, Ativan, Serax Ativan, Xanax, Halcion, Librium, Valium, isorders Have significant potential for dependence in a relatively short time (2–4 time short relatively a in dependence for potential significant Have screening toolsaregenericassessmentstrategies.Assessmentof I dentification rohies, serras, vals, moggies, sleepers, footballs, tamazies, tranx tamazies, footballs, sleepers, moggies, vals, serras, rohies, motivational interviewing T est, atenitemvalidatedquestionnairethattakes , and Klonopin Very . See also links, ‘Benzodiazepines 1:ReasonstoStop’and2:StoppingUse’ORtrythe of withdrawal,referral,preventiondependence–pdf726kb.Patientresources Benzodiazepines GPHandbook(21pages)coveringwhoneedshelptostop?Management synergistically togeneraliseddepressanteffects. overdose butalcoholandbenzosispotentiallyfatal,asethanolopensthischanneladds often. Theydonotactdirectlytoopenchlorideionchannels,andassucharelethalin so thatGABAmoleculesattachtoandactivatetheirreceptorsmoreeffectively Enhances inhibitoryneurotransmitter Examples: a primarycaresetting. low levelsofdependence.Itisaneffective,realistic,efficient andflexibletreatmentoptionin continuing andholisticcare,especiallyforpatientswithlow levelsofproblemseverityand GPs withauniqueopportunitytoreduceandpreventproblematic useofAODasparttheir use …requiringatotalofbetweenfiveminutesandtwohours’ (Heather,1990).BIprovides ‘any interventionthatinvolvesaminimumofprofessionaltime inanattempttochangedrug brief intervention(BI) See also ing anddrug-seekingbehaviour. of thedrugexperience,triggeredbyexposuretoenvironmentalcuesthatinducedrug-crav- persistent changesinbrainfunctionevenafterprolongedabstinence;andthebrain’smemory addictive substances;e.g.druginducedactivationofparticularbrainpathwaysandregions; Studies onpsychoactivedrugsindicatecommonpatternsofalteredbrainfunctionacrossall brain function called abender.Heavydruguseoverlimitedtimeperiodthatcanresultin An episodeofintense(concentrated)orexcessivealcoholdruguse.Aprolongedbingeis binge sometimes Publications & Resources, Professional Resources, & Publications mesolimbic dopamine system/reward centre of the brain mesolimbic dopaminesystem/rewardcentreofthebrain doctor shopping site/page.cfm www.dasc.sa.gov.au/ page.cfm?site_page_id=88 www.dasc.sa.gov.au/site/ overdose. problem solvingandgoalsetting, follow-up. tion (alcohol), brief assessment,self-helpmaterials, informationonsafelevelsofconsump- change including harm reduction, Glossary brief GABA atpost-synapticreceptorsby‘bending’thereceptor GABA motivational interviewing, briefcounselling including relapse prevention, assessment ofreadinessto relapse prevention, from : neuro-adaptation intoxication and 271

Glossary Glossary 272 See also inviting action. building confidence,exchanginginformation,reducingresistanceandsummarising The techniqueconsistsofusingscalingquestions,exploringimportance,summarising, A generictermforthevarious cannabis C See also specific training. State andterritoryregulationsrestrictprescribingtoaccreditedmedicalpractitionerswith overdose riskislowerthanwithotheropioidagonistssuchasmethadone. using shortduration(5–7days)treatment.Withdrawalfrombuprenorphineismilderandthe for opioiddependence.Withdrawalfromshortactingopioids(e.g.heroin)canbemanaged dose dependent,24–48hoursathigherdosesmakingitusefulasamaintenancetreatment demonstrated effectivenessinopioidmaintenanceandwithdrawal.Durationofactionis A syntheticpartialopioidagonistandantagonist;blockstheeffectsofotheropioidshas buprenorphine tions. Twocentralconceptsaredetermining: A techniquedevelopedfortimelimited(lessthan5minutes)andopportunisticinterven- brief motivationalinterviewing

Commonly called Cannabis isthemostprevalentillicitdrugusedtoday(AIHW, 2001). mia. impaired coordination,short-termmemoryloss,tachycardia andsupraventriculararrhyth- Other effectsmayincludeanxietyandpanic,paranoia,visual orauditoryhallucinations, ceptions, increasedappetite,alteredtimeperceptionand difficultieswithconcentration. fects mayincluderelaxation,euphoria,disinhibition,heightened visualandauditoryper- The principalpsychoactiveconstituentisdelta-9-tetra-hydrocannabinol (THC).Acuteef- sativa. sativa. confidence confidence the Cannabis isbothadepressant(atlowdoses),andhallucinogen (athighdoses). importance motivational interviewing motivational interviewing pharmacotherapies about theirabilitytodoso. pot, mull, gunja, kiff, hooch, THC, heads, dope, grass, yarndi grass, dope, heads, THC, hooch, kiff, gunja, mull, pot, tothepatientaboutchangingtheirdrugusebehaviourand psychoactive preparationsofthemarijuanaplant, psychoactive patient centred approach patient centredapproach stages ofchange Cannabis Commonly called ciated withcocaineuseareanxiety,temporarypsychosisandcardiovascularproblems. usually smoked(crack)orinjectedintravenously.Themostcommonclinicalproblemsasso- tained byheatingcocainesaltcombinedwithbakingsoda(freebasing).Cocaineissnorted, cocaine See also or mouth).Bothmethodsincreasevapourconcentrationandeuphoriceffects. mouth ornose)andbagging(vapoursinhaledfromaplasticpaperbagheldoverthenose substances. Othermodesofadministrationarehuffing(saturatedmaterialisheldagainstthe The practiceofinhalingvapoursfromspraypaint.Alsosometimesreferstosniffingvolatile chroming See CDSR C CBT A regularlyupdatedelectroniclibraryofdatabasesandaregister. Itincludes Cochrane Library because ofrapid tic receptorsites.Tolerancetotherewardingeffectsofcocainedevelopsextremelyquickly serotonin atpresynapticlocations,therebyincreasingtheseneurotransmitterspostsynap- and suppressesappetite.Cocaineblocksthereuptakeofdopamine,noradrenaline euphoria, increasedconfidenceandfeelingsofcontrol,energy,reducestheneedforsleep A centralnervoussystemstimulant,derivedfromtheSouthAmericancocaplant.Itproduces treatment/control ofhealthproblems. maintain anddisseminatesystematicreviewsoftheevidence aboutthepreventionand international networkofexperts,(namedtheCochraneCollaboration). Itsaimistoproduce, D care orongoingfollow-upsessionsarelikelycomponentsofsuchaprogram. include socialskillstraining,angermanagement,andbehaviouralself-management.After- patients withcopingandlivingskillstofunctionintheirenvironment.Specifictechniques ognitive atabase of Cochrane Library inhalants B revabstr/g360index.htm www.cochrane.org/cochrane/ www.cochrane.org.au ehaviour S ystematic neuro-adaptation. Crack(purestandmostpotentformofcocaine)isob- coke, snow, C.flake, stardust, white lady, crack lady, white stardust, C.flake, snow, coke, T herapy. Abroadarrayoftherapeuticinterventionsthataimtoprovide R eviews, acollectionofregularlyupdatedhealthcarereviews byan Glossary The DrugsandAlcoholReviewgrouplisting. Email: [email protected]. The Australasian CochraneCentre CDSR, C website. ochrane 273

Glossary Glossary 274 See also approaches todealingwithdualdisorder,whatfrontlinestaff needtolearn,treatmentgoals. Provides asetofinfoslidesfortrainers&GPsincludingcomorbidity; i.e.whichcomesfirst, prevention andtreatment. in PDFformat.IncludesaGeneralPracticeperspective,whatcomorbidityis,howcommon, sionals to identify or anticipate problems related to drug type. Table Table sionals toidentifyoranticipate problems relatedtodrugtype. monly used,broadgroupings(depressant, stimulantorhallucinogenic)canassisthealthprofes- Psychoactive drugsaffectmoods, thoughtsandbehaviours.Despitetherangeofdrugscom- classes ofpsychoactivedrugs Treatment goalofmoderation(cutdown)asopposedtoabstinence. controlled use Describes the1 management approachesandan sential inthemanagementofcomorbidity.Comorbidproblemsgenerallyrequirelong-term consequences foraperson’shealthandwellbeing;thereforeappropriatediagnosisises- (e.g. depressionoranxiety)atthesametime.Interactionbetweentwocanhaveserious Refers toapersonwhohassubstanceuseproblem(s)andmentalhealth comorbidity ordualdiagnosis See also listening andguidanceratherthanprescriptionsareknowntobeeffective. tive responsestodrugproblems.Inattemptingbringaboutbehaviourchange,active A communicationstylewhichisopenandempatheticnon-judgmentalfacilitateseffec- communication style shared care motivational interviewing midasc.htm training_forum/website/ www.ceida.net.au/ nds/new/comorbidity.htm www.health.gov.au/pubhlth/ FUSA/PARC/Publications som.flinders.edu.au/ PARC/toolkitcomorbidresource som.flinders.edu.au/FUSA/ st phaseoftheNationalComorbidityProjectandprovidesdiscussionpapers integrated approach with other services. other with approach integrated Also inPDFformatonthePARCwebsite. Treatment principlesguideforGPs. G–1 lists themajoreffects. Physical dependenceisreferredtoas effects. UsingtheDSM–IVorICD–10diagnosticcriteriaassists diagnosisofdependence. A personastrongdesiretotakedrugordrugsandcannot controltheirusedespiteharmful dependence D A strongdesireorurgetousedrugs,mostapparentduringdrug cravings their responsetoadrug(s). different effectswithdosages,orwhencombinedotherdrugs;individualsvaryin NOTE: Someofthelimitationsclassifyingdrugsinthiswayinclude:manyproduce See also walking pastapub. may betriggeredbyanumberofcues;e.g.seeingdealer,music/objectassociationsuchas long aftercessationofdruguse.Symptomsarebothpsychologicalandphysiological.Cravings Major effectsofpsychoactivedrugs Table G–1 ersat tmlnsHallucinogens opioids, solvents benzodiazepines, e.g. alcohol, barbiturates, slower reactions lowered HR,BP, respiratory Stimulants depression, relaxation &euphoria, coordination; cause awareness & decrease consciousness, Depressants anticraving agents Glossary caffeine, volatile nitrites nicotine, cocaine, e.g. amphetamines, anorexia rate, activity, confidence,heart increase alertness, neuro-adaptation. Thecriteriaappearoverleaf. e.g. LSD, psylocibin subjective awareness distort perceptions and withdrawal and maypersist withdrawal 275

Glossary Glossary 276 consuming it(Proudfoot&Teesson,2000). (ICD–10) suggeststhatthepersonmustpossessastrongdesiretotakesubstanceandis NOTE: TheWorldHealthOrganizationInternationalClassificationofDiseases,10thEdition barbiturates, smalldosesof barbiturates, cation mayresultinstupororcoma.Includedthiscategory is resulting indecreasedconsciousness,awarenessandcoordination. Highlevelsofintoxi- Describes agroupofpsychoactivedrugswhicheffectthe CNSbysuppressingfunctions depressants See TableG–3forthe Psychiatric Association.Providesawidelyuseddefinitionfor dependence.SeeTableG–2. DSM–IV D dependence (continued) tion ofdependence. 7. Substance use is continued despite awareness of recurrent problems associated problems of recurrent awareness despite iscontinued use Substance 7. reduced up or given are activities recreational or occupational Social, 6. 5. or control down to cut attempts unsuccessful or desire isapersistent There 4. was than period alonger over or amounts inlarger taken isoften Thesubstance 3. withdraw the characteristic – Withdrawal 2. to substance ofthe amounts increased markedly for the need – Tolerance 1. period. 12-month same the in time at any occurring following the of more) (or three by characterised is Dependence with use. with recover from itseffects from recover or to substance the to obtain activities necessary in time isspent of A greatdeal use substance intended symptoms substance related) aclosely (or the same the substance of amount same of the use continued or effector achieve intoxication desired iagnostic and ICD–10I S tatistical Manualof cannabis, nternational opiates (i.e.codeine,methadone). opiates C M lassification of a markedly diminished effect with effect diminished markedly a al syndrome for the substance or where or thesubstance for al syndrome ental Disorders(4 is taken to relieve or avoid withdrawal or avoid relieve to taken is D iseases, 10 alcohol, th edn)oftheAmerican benzodiazepines, th editiondefini- See also of use,isadependentuseretc. Alternatives:thispersonexperiencesAODrelatedharm;hasriskypatterns problems ofuse. withdrawal forapersonwhoisdependent.Itmayornotinvolvemedication. prescriptions thanappearstobeclinicallynecessary. year sees15ormoredifferentGPs,has30Medicareconsults,andobtainsPBS often haslittlerelativemeaning.Itisprobablymoreusefultolookat Although substanceabuseisaDSM–IVdiagnosistheterm‘drugabuse’subjectiveand drug abuse The HIC order toobtainlargerquantitiesofprescriptiondrugs. Common termfordescribingthepracticeofvisitingmanydoctorsoveraperiodtimein ‘doctor shopping’ Is synonymouswithandmorecommonlytermed detox/detoxification ICD -10definitionofdependence Table G–3 1. period. 12-month same time inthe at occurring any following of the by three(or more) ischaracterised Dependence 2. 3. 4. 6. 5.

(Health InsuranceCommission) models ofdruguse required to achieve the same effects originally produced by lower doses. by lower produced effects originally the same achieve torequired are the substance of doses that increased such evidence, – Tolerance withdrawal symptoms. avoiding relieving/ of the intention with substance use ofsame the or for substance the syndrome characteristic withdrawal bythe evidenced ceased, has reduced/ use substance when state physiological – Withdrawal Compulsion to use – strong desire or compulsion to take the substance tothe take ordesire compulsion –strong to use Compulsion the extent of harm. ofthe extent of to aware be, be expected could actually, or was user thatdetermine the to be taken Efforts should consequences. harmful of evidence use despite persisting withsubstance – harmful consequences usedespite Continued recovering). using and obtaining, of time (increased amount use substance to due interests other of – neglect prioritised use Substance of use. levels and termination such asonset, behaviour, substance controlling in difficulties – use controlling Difficulties Glossary defines a‘doctorshopper’assomeonewhoinone withdrawa l. Usuallyitreferstosupervised patterns ofuseand 277

Glossary Glossary 278

munity initiativescanbeaccessedatthefollowingwebaddress. TheCommunityPartner- ing communitywideeducationandinformationcampaigns onillicitdrugs.Oneofthecom- ling andreferralservicesthroughcommunitybasedprograms aswellaugmentingexist- The NationalIllicitDrugStrategystressestheimportance of increasededucation,counsel- education (communityfocus) Commonly called symbol impressedonthesurface. in additionto,orplaceofMDMA.Itisusuallysoldasa tablet orcapsule,typicallywitha such asamphetamine,amphetaminederivatives,caffeine, aspirin,paracetamol,ketamine ever otherdrugsmaybesoldas‘ecstasy’,and‘estasy’tabletsoftencontainarangeof The streetnamegenerallyusedfor3,4-methylenedioxymethamphetamine(MDMA).How- ‘E’ orecstasy E Some patientswillexhibitmultiplestatesoveraperiodoftime. require considerationwhenworkingwithpeoplewhohavedrug-relatedissues. drawal tional functioning.Drugstates– Conditions inducedbydrugusethatmayimpactonphysical,cognitiveandsocial/emo- drug states See also behaviour, recoveringfromdruguseandwithdrawal. starts withtheacquisitionofdrugsandmovesthroughadministrationdrugs,drugaffected and dependence).Itcanalsobeviewedtemporallyasacycleofdrug-relatedbehaviourthat This hasbeendescribedinvariousmodels(e.g.Thorley’smodel–intoxication,regularuse, drug-related behavioursandharms Two ormorepsychoactivedrugsinteractwitheachotherinoneofthreeways: drug interactions

tabolism ofalcoholbeyondacetaldehyde. e.g. alcoholandbenzodiazepinesenhancesedation; interference potentiation antagonism patterns ofdruguse health.gov.au/ www.communitypartnerships. , onedrugcancelsouttheeffectsofother,see , combinedeffectsthatexaggerateandincreasetheofeachdrug; , onedrugdisruptstheactionofother;e.g.disulfirampreventsme- white doves, love hearts, eccy, Adam, XTC Adam, eccy, hearts, love doves, white intoxication, Reflect. action researchmodel:Look, Think,Act& vent harmsrelatedtoillicitdrug use.Itusesan wishing toundertakecommunity actiontopre- ships Kitwebsiteisaresource forgroups overdose, overdose, dependence/tolerance and dependence/tolerance antagonist; with- conditions incontrastto The degreetowhichaninterventionproducesdesiredoutcomesundereveryday,normal effectiveness tion approaches. activities toinvolveparentsandotheradultsinthelearningprocessaswellearlyinterven- 12). Theseincludeteachersupportmaterials,learningactivitiesforstudentsandtake-home There isarangeofStateandNationaldrugstrategyinitiativesfromReceptiontoYear12(R– education (schools) patient information. base. Thisexchangeofinformationcanbereinforcedandextendedbyprovidingpublished implies beinganactivelistenerandrespondingtogapsinapatient’sknowledgeskill their conditionandcanmakeaninformedchoiceaboutwhattodo.Educatingpatients GPs arewellplacedtoprovideinformationpatientssothattheybetterinformedabout education (patientfocus) E Evidence BasedPractice(EBP) the localpopulationorservice. Caution shouldbeexercisedininterpretingtherelevancyofresultstoaGP’ssetting, conditions suchasthosecarriedoutinaresearchsettingwithhighlevelsofresourcing. The degreetowhichaninterventionproducesdesiredoutcomesunderoptimalorideal efficacy of evidence regardingeffectiveness,trythefollowingdatabases: and MEDLINE. See also Alcohol ReviewsandprotocolsgototheCochranewebsite. professional expertiseandpracticalwisdom,toapplyitdecision-makingpractices.Itpro- vidence S ystematic gold standards B revabstr/g360index.htm www.cochrane.org/cochrane/ ased R eviews), DARE( P ractice integratesandreviewsthebestavailableresearchevidence,with efficacy, i.e.interventionsunder‘ideal’conditions.Tosearchfor efficacy, Glossary D atabase of A bstracts of For themostup-to-datelistingofDrugsand dence toguidehealthcaredecisions. use ofthebest,mostup-to-dateresearchevi- motes theexplicit,conscientiousandjudicious R eviews of CDSR ( E ffectiveness), EMBASE C ochrane D atabase 279

Glossary Glossary 280 of gammaaminobutyricacid ( tion beinginthebrainwhere (unlike GABA)itcrossestheblood–brainbarriertoaffect the GABA atpost-synapticreceptors,hencetheirdepressant action. receptors canbefoundat60–80%ofCNSneurons.Benzodiazepines enhancetheeffectof aptic releaseofneurotransmittersduetoapositivevoltage polarizationpulse.GABA gating negativechloride(Cl-)ionsintotheinteriorofnerve cells,GABAinhibitsthepresyn- G GHB G GABA G S E M A R F successful briefinterventions: A treatmentmodel(Miller&Sanchez,1993)withsixtherapeuticstepsthatarecommonto FRAMES logical/social supportandadaptingtreatmentplansaccordingtopatientneeds. An essentialprocessinmonitoringtheoutcomesoftreatment,providingongoingpsycho- follow-up See also S G A L F A treatmentmodelinrelationtoAODpatients.Theconsistsoffivesteps: FLAGS F isten topatient’sconcerns eedback (giveresultsofscreening) eedback trategies fortreatmentarediscussed,implementedandmonitored. elf-efficiency mpathy dvise patientsaboutcontinueduseofdrugs esponsibility dvice amma amma- oals oftreatmentshouldbedefined enu h a FRAMES mino ydroxy b utyric b utyric acid( a cid isthemostimportantinhibitoryneurotransmitterin CNS. By GHB) isanaturallyoccurringshort-chain fatty acidmetabolite GABA). Itisfoundin allbodytissues,thehighestconcentra- GABA). Common namesinclude other drugs(ecstasy,alcohol,amphetamines,cannabis). There isanarrowmarginofsafetywithoverdosebeingcommon.Ittypicallytaken slipped intodrinksandfood.Ithasbeendescribedas‘likealcoholwithoutthehangover’. manufacture (recipes’areavailableonwebsites),hasnocolourorsmell,andcanbeeasily GHB isusedasa‘partydrug’and‘drug-rape’drug.Itcomesinliquidform,easyto dopamine concentrationsandinduceshypothermia. indicates thatGHBproducesdeepreversibledepressionofcerebralmetabolism,increases hydroxytryptamine, acetylcholineandaffectstherateofserotoninmetabolism.Research activity andlevelsofneurotransmitters.ItisinvolvedintheregulationGABA,dopamine,5- Examples: bances inthoughtandperception (e.gillusions,andoccasionallyhallucinations). Substances thatinteractwith the CNSaffectingstateofconsciousness,andproducingdistur- hallucinogens ‘peak effects’thandrugswithalongerdurationofactionand longerhalf-lives. a shorthalf-lifeanddurationofactionarecommonlyused (e.g.heroin)becauseoftheir The timeittakesfortheconcentrationofadruginblood tobereducedby50%.Drugswith half-life H Examples: accepted assuchbythemedicalcommunity. ‘gold standard’issaidtohavethehighestqualityandvalidityatpresenttimebecome The goldstandarddemonstratesahighlevelofconfidencethattheresultwillre-occur.A gold standards try ‘DrugInfo,ResearchProjectSheets’link: GHB use,patternsandassociatedharms(2001)basedoninterviewswith76GBHusersOR Liquid X. Liquid ndarc.nsf/website/home ndarc.med.unsw.edu.au/ DrugInfo.resprojfactsheet ndarc.nsf/website/ ndarc.med.unsw.edu.au/ AUDIT asascreeningtooltoassessalcoholrisk Methadone asapharmacotherapyforopiatedependentpatients LSD, Psylocibin(MagicMushrooms) Fantasy, Grievous Bodily Harm, GHB, Liquid ecstasy, Liquid E, Liquid ecstasy, Liquid GHB, Harm, Bodily Grievous Fantasy, Glossary 281

Glossary Glossary 282 environment/ settingandthedrug(s). Intervention oftentargetsaspecificgroup( A setofsequencedandplannedactionsdesignedtoreduce riskybehavioursinsociety. interventions and rapidintoxicationwithaccompanyingresolution ofintoxication. stances. Theirappealislinkedtobeinginexpensive,readily obtainable,easyconcealment glue andpaintthinnerscontainingtoluene.Alternatively calledsolventsorvolatilesub- include petrol,lacquersandvarnishescontainingbenzeneadhesives,spraypaint, liquid orsemisolidstatetovapourwhenexposedair.Themostcommonlyusedinhalants A groupofpsychoactivesubstanceswhichareCNSdepressants,rapidlychangingfroma inhalants legislation. drug’. Classificationoflegalstatusvariesovertimeaccordingtosocietalattitudesand A drugwhoseproduction,saleorpossessionisprohibited.Analternativeterm‘Illegal illicit drugs I phlets opioid dependency,experimental,supervisedinjectingfacilities,briefadvice,infopam- Examples: reduction methods. edges thatdruguseexistsandwillcontinueto,thereforeitfocusesonpromotingharm encompassing thepreventionofdisease,death,incarcerationandisolation.Itacknowl- nity level.Itincludesreducingthephysicalandsocialharmsassociatedwithdruguse, Aims toreducetheimpactofdrug-relatedharmwithinsociety,atanindividualandcommu- harm reduction reduction harm sive approachtodrug-relatedharm,involving ing anticipatedharmandreducingactualfromlicitillicitdrugs.Itisacomprehen- economic outcomesforthecommunityandindividual.Harmminimisationincludesprevent- Underpinned theNationalDrugStrategyandaimstopromotebetterhealth,social harm minimisation onymous withtreatmentplanactivities,whicharenegotiated withthepatient. potentially harmfulbehaviours(suchasdruguse).IntheGP settinginterventionsaresyn- clean needlesandsyringeprograms,methadoneasatreatmentoptionfor strategies.Ittakesintoaccountthreeinteractingfactors:theindividual, risk group) inordertoreducetheadoption of risk group) demand reduction, reduction, demand supply reduction supply and Commonly called of consciousness. comes inliquid,pill,powderandtabletform.Injectingketaminesmaycauseimmediateloss try inliquidform;howeveritiseasytoconvertintopowderformbyheatingandgrinding.It experiences athighdoses.Ketamineissyntheticallyproducedbythepharmaceuticalindus- high dosesapowerfulparalysingpsychedelic–andpossibleout-of-bodyorneardeath rapid andusuallylastfrom45–90minutes.Lowdosesproducestimulanteffects;mediumto with painpathways,leavingtherespiratoryandcirculatoryfunctionsintact.Theeffectsare Fast-acting dissociativeanaestheticscommonlyusedasanimaltranquillisers.Theyinterfere ketamines K See also tolerance. Thecapacitytothinkandactwithinanormalrangeofabilitydiminishes. or physicalchanges.Whenintoxicatedtheamountofadrug(s)exceedsindividual’s The acuteeffectsofadrugwhentakenonsingleoccasionthatproducebehaviouraland/ intoxication See also major predictorsofrelapserisk. absence ofcopingskillsandcertainbeliefsystems(e.g.‘I’m anaddictandcan’tstop’)are relapse isnot‘failure’butasteptowardsbehaviourchange. Researchindicatesthatthe use oratlevelssimilartothosepriorabstinence.Itis importanttorecognisethatlapse/ The firstuseofdrugsafteraperiodabstinence.Arelapse referstoareturnuncontrolled lapse/lapse–relapse cycle L LAAM L such as ence. LAAMhasdurationofaction48–72hours,considerably longerthanotheropioids evo- a lpha- methadone. Currently(2003)notavailableinAustralia. drug-related behavioursandharms relapse a ketamine/effects.htm www.thegooddrugsguide.com/ cetyl- special k, kitkat, vitamin k, ‘k’ and ket. and ‘k’ k, vitamin kitkat, k, special m ethadol, anopioid Glossary agonist usedforthemanagementofopiatedepend- ketamine andotherdrugs. A consumer-orientedinformationsiteon 283

Glossary Glossary 284 This modelstressestheimportance ofpharmacotherapyintreatingdruguseproblems. causes andthephysiological andpsychologicaleffectsthatareinducedbydrugtaking. Controlled useispossible. quences, itislearned(thereforecanbe‘unlearned’)and thesocialsettingisimportant. Zinberg’s modelsuggeststhatdruguseisfunctionalwithboth positiveandnegativeconse- drug itself,theperson,andsocialsettingorenvironment inwhichdrugusageoccurs. ing anationallyaccreditedmethadoneprescribers’course. The Medical model Medical The model Zinberg’s Examples: vidual andcommunitylevel. Frameworks toassistinunderstandingdifferentperspectivesaboutdruguseatanindi- models ofdruguse relieve heroinwithdrawaldiscomfort. effects last24hourswithregulardosing.Itmayalsobeusedshort-term(5–30days)to are dependentonopioids.Methadoneliquidisusuallyadministeredoncedailyasthe A syntheticopioidagonistpredominantlyusedinmaintenancetherapywithpatientswho methadone See also make lifestylechanges. pharmacological stability(i.e.relieffromwithdrawal/intoxication),allowingthepatientto A drug(e.g.methadoneorbuprenorphine)isprescribedonalong-termbasistoprovide maintenance pharmacotherapy/drugsubstitution A stageofbehaviourchange,inwhichadependentuseractivelytriestoremainabstinent. maintenance M Examples: term. A drugwhoseproduction,saleorpossessionisnotprohibited.‘Legal’analternative licit drugs (DRIP, DRIP)andintoxication. interactive andoverlappingareasofdruguse–dependence (being‘STUCK’),regularuse relapse/relapse prevention Thorley’s model Thorley’s Alcohol, tobacco,benzodiazepines,someinhalants (basedonSocialLearningTheory)considersthreeinteractive factors–the emphasisesdruguse(addiction)asadiseaseduetogenetic/biological identifiesdrug-relatedproblems/harms,derivedfromthree

GPs canbecomemethadoneprescribersbycomplet- See also ing tocommunicateunderstanding,elicitingself-motivationalstatements of quences ofdruguse,exploringpatient’sconcerns,usingreflectivelisteningandsummaris- Examples with supportfromtheGP. patient isencouragedtoargueforchange(nottheGP)andprovidetheirownsolutions ambivalence intheirpatientsandexplorepatient’sreasonstochangedruguse–the This isacounsellingtechniquedevelopedbyMillerandRollnick.ItassistsGPstoworkwith motivational interviewing models ofdruguse(continued) comprehensive approach,whichencompassestheuseof bothlicitandillicitdrugs. mise theharmfuleffectsoflicitandillicitdruguseinAustraliansociety.TheNDSadoptsa community. TheNDSaimstopreventandreducetheuptakeofharmfuldrugusemini- Refers toaframeworkofpoliciesandprogramsaimedatreducingdrug-relatedharminthe National DrugStrategy(NDS) dopamine releaseinresponsetocues;e.g.druguseimplements. users thiscanleadtochronicandintensecravingswhichmaybeactivatedbyanticipatory rienced previouslyleadstoadesirefororrepetitionofthebehaviour.Inchronicsubstance psychoactive substances.Theintensefeelingfromactivationoftherewardorpleasureexpe- the prefrontalcortex.Itisactivatedbynaturalrewardssuchassexualactivitywell A pathwayinthebraincomprisingventraltegmentalarea(VTA),nucleusaccumbensand mesolimbic dopaminesystem/rewardcentreofthebrain to change things you like and dislike about your cannabis use?’) use?’) cannabis your about dislike and like you things brief motivationalinterviewing (e.g. ‘where does this leave you now?’). you leave this does ‘where (e.g. tmpl/page2ofcrack www.sociology101.net/sys- strateg/drugs/illicit/index.htm www.health.gov.au/pubhlth/ strateg/drugs/nds/index.htm www.health.gov.au/pubhlth/ motivational interviewingactivities–exploringpositiveandnegativeconse- Glossary stages ofchange 1998–99 to2002–03 Describes theNationalIllicitDrugStrategy PDF file,393Kb. 99 to2002–03. Describes theNationalDrugStrategy1998– helping thepatienttodecidewhether models/-20k- www.bali3000.com/drugnet/ (e.g. ‘what are the are ‘what (e.g. 285

Glossary Glossary 286 receptor siteinvolvestwotypesofaction: pying theneurotransmitter’sposition.Theinteractionbetween thedrugmoleculeand molecules canbehavelikeneurotransmitters,bindingtoa particular receptorsiteandoccu- They bindtoparticularreceptorsites,excitingorinhibiting anaction.Psychoactivedrug Chemical messengersthatarereleasedbyneuronesto communicate acrosssynapses. neurotransmitters the drug’seuphoriceffects. (without drugs),areductionineuphoria/pleasureandneed toincreasethedosemaintain nisms. Thisisoneexplanationforcraving.Thedrugusermay experienceunder-stimulation relatively insensitivetonormallevelsofneurotransmittersby anumberofpostulatedmecha- The processwherebythebrainadaptstopresenceofadrug.becomes neuro-adaptation N NEPOD (1998–2000) of initiation,Australia,1998,2001ORtry‘FactSheets’linkfrom: Summary ofdruguse:proportionthepopulationaged14yearsandover,meanage Health andWelfarecanbefoundontheirwebsite 2001 NationalDrugStrategyHouseholdSurvey:FirstResultsispublishedbytheInstituteof 1985. 14 yearsandover.Previoussurveyswereconductedin1998,1995,1993,1991,1988 taken inAustralia.The2001surveygatheredinformationfromalmost27,000personsaged This isthemostcurrentandcomprehensivesurveyconcerninglicitillicitdruguseunder- National DrugStrategyHouseholdSurvey(NDSHS) because ofitsuniquepropertiesshouldalsobeconsidered. ments providedbenefitsandthatmethadonewasthemostcost-effective;buprenorphine, withdrawal treatmentsandmaintenancetreatments.Itfoundthatalltreat- tions foropiate(heroin)users.Thirteenstudieswereconductedwhichinvestigateddetox/ A three-yearclinicaltrial(1998–2000)whichmonitoredtheeffectivenessoftreatmentop- ational E valuation of DrugInfo.factsheets ndarc.nsf/website/ ndarc.med.unsw.edu.au/ www.aihw.gov.au/ P harmacotherapies for O piate D ependence. ndarc.nsf/website/home ndarc.med.unsw.edu.au/ Examples: stipation, sedation,unconsciousness,coma;toleranceanddependence. Potential adverseeffectsincluderespiratorydepressionandarrest,nausea,confusion,con- physical dependencewithaccompanyingstrongwithdrawalsyndromeoncessationofuse. (highly reinforcing).Regularuseleadstotoleranceaccompaniedbycravingforthedrugand stimulate opioidreceptors,producingdrowsiness,reducedpainperceptionandeuphoria heroin orsynthetic;e.g.pethidine;theyaremostlyusedasanalgesicsforpain.Opioids nist naloxone.Morphineisderivedfromtheopiumpoppy;othersaresemi-synthetic;e.g. A classofsubstanceswithmorphine-likeeffectsthatcanbereversedbythespecificantago- opioids/opiates O Antagonist ecule willthereforeoccupythereceptorsiteandimitateneurotransmitter’saction. Agonist piratory depressionwithopiates. include acutepsychosis(e.g.amphetamines)orpotentiallylifethreateningeffects;e.g.res- Results fromtheingestionofadrug(s)thatexceedsperson’stolerance.Theresultmay overdose dine, diconal,palfium from exertingitsaction. occupy thereceptorsite,butnotimitateitsactions.Thedrugpreventsneurotransmitter Overdose categoriesofconcern Table G–4 vital functions Drugs thatdepress alcohol benzodiazepines + heroin, Thedrug’sshapemaybesimilartotheneurotransmittermolecule.drugmol- Thedrug’sshapemayresembletheofneurotransmittermolecule,and opium, heroin,morphine,codeine,fentanyl, Glossary e.g. paracetamol alcoholanalgesics or toxic effects Drugs thathave methadone, methadone, work harder organs and systems to stimulants which cause on internal organs stress cause that Drugs buprenorphine, pethi- buprenorphine, 287

Glossary Glossary 288 comprehensive treatmentplanthatincludespsychosocial therapiesandsupport. done ortoreducecraving;e.g.naltrexone.Pharmacotherapies arebestusedaspartofa can beusedtoalleviatewithdrawaldiscomfort,asmaintenance substitution;e.g.metha- Involves theuseofmedicationsinrespondingtoproblem drugdependence.Medication pharmacotherapies dependent patternsofuse. ally moveupthe‘scale’andprogresstowards mental oroccasional.Somepeoplegradu- continuum andthatmostdruguseisexperi- This modelsuggestsdruguseexistsasa patterns ofdruguse See also provided indifferentlanguagestocaterforthebroadcommunity. cian) forms.Passivepatientinformationisusuallyfreeorofminimalcostandneedstobe be providedinpassive(pamphlets,posters,booklets)andactive(consultationwithphysi- Refers toeffectivestrategiesinprovidingpatientswithrelevantinformation.Informationcan patient information See also users andenhancethelikelihoodofbehaviourchange. strategies havebeenempiricallydemonstratedtoenhancethequalityofsupportdrug ments/confrontation, encouragingdiscrepancyandrevaluationofsubstanceuse.These thy, encouragingthepersontodecidehowmuchofaproblemtheyhave,avoidingargu- the patient.Itincludesregardingperson’sbehaviourastheirchoice,expressingempa- This isrecommendedinordertoencourageagoodtherapeuticrelationshipandtrustwith patient centredapproach benzodiazepines, cannabis. Individuals whousepartydrugsoftentakeotherdrugs;e.g.alcohol,antidepressants, Examples: stimulants. A termthatlooselygroupsdrugsusedinthepub,club,partyorravescenes.Includes party drugs P The simultaneousorsequential non-medicaluseofmorethanonedrug. polydrug use ADIS motivational interviewing motivational interviewing amphetamines, MDMA(Ecstasy),GHB,ketamine stages ofchange

E E X X

O P P

RECREATIONAL C E E C R R

Regular A Dependent I I S M M I O E E N N N A T T L A A

L L

tertiary. lems amoungthoseusingdrugs.Interventionscanbecategorisedasprimary,secondaryor Interventions thataredesignedtostopordelaytheuptakeofdrugsreducefurtherprob- prevention use duringpregnancyandexploringarangeofchoicesforaction. ment strategiesincludeprovidingpatientinformationabouttheeffectsofdrugandalcohol the woman’slastmenstrualperiodandwhetherornotsubstanceuseiscontinuing.Manage- Assessment includesquestionsabouthistoryofalcoholandotherdrugusefromthedate Examples: Drug andalcoholusethroughoutpregnancyisassociatedwitharangeofadverseeffects. pregnancy anddrugs illicit drugs.Italsoreferstoother substancesthathavepsychoactiveeffects;e.g.solvents. and behaviour.Theterm‘drug’usuallyincludestobacco,alcohol, pharmaceuticaldrugsand Refers toanychemicalsubstancewhichwhentakeninto thebody,altersmood,cognition psychoactive drugs Table G–5 substance users. substance Individuals who are dependent or heavy Tertiary Increase awareness about the risks Individuals who are already using drugs Secondary drugs have already begun experimenting with Individuals who are likely to– orwho Primary Fetal AlcoholSyndrome(FAS) Neonatal AbstinenceSyndrome(NAS) vulnerability toinfection Reduced birthsizeandweight,oftenleadstobreathingdifficulties (miscarriage) andstillbirth Increased incidenceofprematurelabour,riskspontaneousabortion YEADTRE FOCUS TYPE ANDTARGET Glossary Treat and rehabilitate of drug-related harm involved, in order to reduce the amount reduce frequency ofuse to preventaims uptake druguse or of Educate about drug-related harm, and 289

Glossary Glossary 290 antidepressants actviatheireffectsonserotonin;e.g.inhibition ofreuptake. increased bystimulants,especiallyMDMA.Itsreleaseisinhibited byopioidreceptors.Many Serotonin isaffectedbyanumberofpsychoactivesubstances. Itssynapticconcentrationis A phenolicamineneurotransmitterthathasaprominentrole insleepregulationandmood. serotonin (5hydroxytryptamine) Examples are notdesignedtoreplaceagoodhistorybutcomplementaryto,andtimesaving. information andfacilitatefurtherdiscussionbetweenthepatientGP.Screeningtools Questionnaires thatassistinscreeningfordruguseandrelatedharms.Theyprovideuseful screening tools thoughts oractions. A preoccupationwithsubstanceuse,orseekingthesubstance.Itdominatesuser’s salience S sionals. transgender andintersexgroups,AboriginalTorresStraitIslandershealthprofes- lation. These‘at-risk’groupsincludeoutpatientgroups,youth,gay,lesbian,bisexual, tially atgreaterriskofharmthroughintended/actualdruguse,relativetothegeneralpopu- Surveys, reviewsandepidemiologicaldataindicatethatcertaingroupsinsocietyarepoten- risk/‘at-risk’ ofAODrelatedharms See also risk situationsthatmayleadtopreviouspatternsofdruguse. Relapse preventiondescribesasetofstrategiesthataimtoequippatientscopewithhigh- another stepinajourney,notasfailure. takes timeforanyonetochangetheirbehaviour.Encouragepatientsviewrelapseasjust Relapse isacommonlydescribedfeatureofthosepatientswhoaredrug-dependent.It relapse/relapse prevention R motivational interviewing ASSIST foralcoholandotherdruguse SDS forpsychologicaldependence AUDIT, FAST(basedontheAUDIT)&CAGEforalcoholuse cons). ments bankthatcanbedownloaded;EuropeanUnionfocus. bilitation, anin-depthstudyonsocialreintegrationfacilitiesandhasevaluationinstru- The EuropeanMonitoringCentreforDrugs&DrugAddictionwebsitedescribessocialreha- viewed asaninterventionthatcanbeusedatanystagethroughoutthetreatmentprocess. ally socialrehabwasprovidedaftercompletionofatreatmentprogrambutitisincreasingly An interventiontointegrateclientsintosocietythrougheducation,workorhousing.Tradition- social rehabilitation ongoing educationandtrainingforGPs. services byGPsandspecialistAODagenciestothosepatientswithproblems or complexconditions.TheAODsharedcaremodelfocusesonjointprovisionofclinical An integratedapproachtoprovideeffective,planneddeliveryofcareforpatientswithchronic shared care through withwhatyousay. and ‘upfront’inwhatyousay,meansaymean,follow is lessroomforfeelingcompromisedorused.Thebasicprinciplesarebeingclear,concrete Setting limitscanhavebenefitforbothGPsandpatients.Consequencesareclearthere setting limits See also Relapse Maintenance They becomeactivelyinvolvedinattemptingtochangetheir behaviour. Action Contemplation Pre-contemplation Prochaska andDiClementedescribedamodelwithfivedistinctstagestobehaviourchange: stages ofchange with analternativeone. –theindividualisatstagewheretheywanttodosomething aboutthebehaviour. motivational interviewing motivational interviewing social_reintegration.shtm responses/themes/ www.emcdda.org/ –theindividualattemptstomaintaintheirprogressbyreplacing thebehaviour –theindividualisbeginningtoquestionbehaviour(weigh upprosand –theindividualmaynothaverecognisedtheyaproblem Glossary patient centredapproach 291

Glossary Glossary 292 U that existwithinandoutsidetheGPsetting.Thereisarange oftreatmentoptions. lem/habit, thesocialandenvironmentalcontextinwhich patientlivesandtheresources The choiceoftreatmentoption(s)dependsuponthenature andseverityofthedrugprob- treatment options/modalities lower dosage. Increased dosesarerequiredtoachievethesamelevelof effectpreviouslyproducedbya A stateinwhichcontinueduseofadrugresultsdecreasedresponsetothedose. tolerance counselling, grouptherapy,andotherself-helpstrategies. dential programs(oftenatleast3months)thatprovideaholisticapproachtotherapyvia (National DrugStrategicFramework,1998).Therapeuticcommunitiesarelong-termresi- ‘A structuredresidentialenvironmentinwhichpeoplelivewhilstundergoingdrugtreatment’ Therapeutic Community(TC) Delta-9-tetrahydrocannabinol, theprimary THC T sale ofalcoholandtobaccotopeopleundertheage18. impose limitsonaccesstoandtheavailabilityoflicitdrugssuchaslegislationregulating Activities thataimtodisrupttheproductionandsupplyofillicitdrugs.Itmayalsobeused supply reduction change andislesslikelytoresultinmisunderstanding. It isrecommendedthatGPsusemedicalterminologysincethisstandard,lesssubjectto There aregoodlistingsofstreetlanguageandtheirmeaningsinanumberpublications. street language/names after chronicuse. drugs suchasantidepressantsandcertainopioidshavestimulanteffectsinhighdosesor caffeine, phetamines, Any drugsthatactivate,enhanceorincreaseneuralactivityoftheCNS.Includes stimulants It includesillicit,socialandprescription drugs. Drug usethatisproscribedby law,schoolauthoritiesorpoliciesand/orguidelines. unsanctioned druguse cocaine, nicotineandsyntheticappetite-suppressants.Someother cocaine, psychoactive constituentincannabis. psychoactive am- See also illicit druguse,especiallythelong-termhealtheffects. cially ontheInternet)theyneedinformationhealthconsequencesassociatedwith parents and/orcarers.Althoughyoungpeoplehaveaccesstoillicitdruginformation(espe- sources andareinagoodpositiontodeliverinformationonillicit/licitdruguseyouth, Youth areahigh-riskgroupfordrug-relatedharms.GPsviewedascredibleinformation Youth Y the psychosocialenvironment. course ofthewithdrawaldependsuponleveltolerancedeveloped,otherillnessesand high doses.Generally,signsandsymptomsareoppositeoftheacuteeffectsdrug.The or substantiallyreducessubstanceuseiftheyhavebeenusingforalongperiodor/andat Describes arangeofphysicalandpsychologicalsymptomsthatoccurwhenpersonstops withdrawal syndrome W intervention activities.Thiscontrastswiththepolicyof A policythatpromotestheidea‘nodrugs’,druguse’isaimofeducationand zero tolerance Z patterns ofdruguse www.ysas.org.au/ Glossary Youth SubstanceAbuseService,Victoria harm minimisation. 293

Glossary Glossary 294 WHO (WorldHealthOrganization)1994, Proudfoot, H.&Teesson,M.2000, Heather, N.1990,citedinAli,R.,Miller,M.&Cormack,S.1992, Miller, W.R.&SanchezM.C.1993,‘Motivatingyoungadultsfortreatmentandlifestyle AIHW (AustralianInstituteofHealth&Welfare)2001, REFERENCES Drug andAlcoholResearch of NotreDamePress,Dame,pp.55–79. PHE 41,AIHW,Canberra. change’ citedinHoward,G.(ed.), Household Survey: Detailed Findings Detailed Survey: Household Alcohol and Other Drug Treatment in Australia in Treatment Drug Other and Alcohol Centre, Sydney, Issues in Alcohol Misuse by Young Adults Young by Misuse Alcohol in Issues Investing in Drug and Alcohol Treatment Alcohol and Drug in Investing Lexicon of Alcohol and Drug Terms Drug and Alcohol of Lexicon , DrugStatisticsSeriesNo.11,AIHWcat.no. www.ndarc.med.unsw.edu.au. , AGPS,Canberra. 2001 National Drug Strategy Drug National 2001 Future Directions for Directions Future , WHO,Geneva. University , National