PRIMARY Mental Health Care Module 7:Management of substance abuse and addiction

1. PRIMARY Mental Health Care Module 7:Management of substance abuse and addiction Presentation by : Mrs. M.A.Charles Deputy Manager : Substance Abuse Services

2. Session One:Why the brain prefers cocaine to cabbage Addiction is a brain disease

3. Normal brain function • Goal: survival of individual and species • Necessary activities: eating, reproducing, nurturing young, staying safe. • Necessary activities are experienced as pleasurable. • We repeat these “feel good” activities over and over, until many are habitual … and our children, grandchildren, great grandchildren survive after us

4. Addictive drugs hijacknormal brain functions! How?

6. Dopamine – a brain messenger (neurotransmitter) Dopamine helps brains learn: More dopamine – experience better than expected Less dopamine – experience worse than expected No change – experience as expected (no new learning)

7. All addictive drugs INCREASE amount of dopamine Therefore: Every drug experience is “better than expected” Brain tells us to repeat these “better than expected” experiences We develop linked memories of Cues that trigger wanting of the drug Activities that help us obtain, use drug

8. Addictive behavior Cue triggers overwhelming craving (wanting) of drug Wanting activates automatic behaviors (habits) to get and use drug Rational, control part of brain (PFC) underdeveloped All priorities overwhelmed by priority for drug Drug use becomes “survival behavior” for addicted person (brain cell communication may be permanently changed)

9. Effect of methamphetamine on the brain

10. Addiction: chronic brain disease Repeated use of addicting drugs damages normal structure and function of brain. Addicted brain responds abnormally to usual stimuli years after end of drug use. Addicted brain has decreased capacity to set priorities and make rational decisions around drug use Many brain changes appear to be permanent – although other parts of brain may compensate

11. Session Two Knowledge: • Describe basic terminology associated with substance use and abuse. • Trends in substance dependency. • Learn about patterns substance use/ abuse/addiction. • Identify drugs; methods of use and its’ short and long term effects. • Learn procedures for management of drug overdose. • Know about treatment modalities resources

12. WHAT IS A DRUG? A drug is any CHEMICAL SUBSTANCE (natural or artificial) that is used with the INTENTION of bringing about CHANGE in the way the brain & / or body functions. What are psychoactive substances? These substances exert an effect on the brain Drugs of abuse are PSYCHOACTIVE. Includes psychotropic medication used without prescription. Psychoactive substances may be licit and illicit and can lead to dependence: naturally occurring substances can be found in plant and animal tissue (cannabis; tobacco); Semi synthetic- chemical manipulations of substances extracted from natural plant or animal tissue (cocaine; alcohol; heroine) and Synthetic drugs- not found in nature, but created in laboratories (ecstasy;mandrax; methamphetamine (TIK) and methcathinone

13. Psychoactive substances (DEPRESSANTS) SEDATIVES Alcohol Mandrax Heroine;opium OTC-Sleeping tablets STIMULANTS (Uppers) Caffeine Nicotine Cocaine / crack MDMA-type;Ecstasy; Methcathinone(CAT;speed Methamphetamine-TIK;meth; ice • HALLUCINOGENICS • Cannabis (Dagga) • LSD (Acid) • Magic mushrooms • INHALANTS/SOLVENTS • Poppers –liquid gold/TNT • Glue; • petrol;Benzene; • meths

14. Substances abused in South Africa Three categories according to levels of use: EXTENSIVELY USED: Alcohol ; tobacco; Cannabis (Dagga)&mandrax ; tik; OTC; solvents MODERATELY USED :Heroin (“Sugars”) ;OTC ;crack cocaine; speed; LSD; hashish; methamphetamine and ecstasy INFREQUENTLY USED: opium; Rohypnol; ketamine; wellconal

15. DRUG DEPENDENCE SYNDROME Stage 1 : Experimentation “Once won’t hurt!” Stage 2 : Occasional Use “Sometimes is ok” Stage 3 : Regular Use “I can handle it” Stage 4 : Dependence “It’ll hurt to stop”

16. ALCOHOL : (Booze, dop, utshwala, shot, shooter, snorts…..) A CNS sedative drug – slows you down! Short-term effects- Loss of physical coordination; unclear vision; slurred speech Excessive drinking over a short period of time: headache; nausea; vomiting; deep unconsciousness and death. Long term: loss of appetite; vitamin deficiency; skin problems; loss of sexual drive; liver and brain damage Foetal Alcohol Syndrome Tolerance and dependence develope

17. DEFINITIONS ALCOHOLISM IS AN ABNORMAL BIOCHEMICAL REACTION OF THE BODY TO ALCOHOL. AN ALCOHOLIC IS A PERSON WHO CANNOT AT ALL TIMES CONTROL HIS/HER DRINKING & THEREFORE EXPERIENCES PROBLEMS IN OTHER AREAS OF HIS/HER LIFE.

18. IDENTIFYING THE ALCOHOLIC Signs of alcohol abuse If you observe someone with the following physical signs, suspect alcoholism: • alcoholic breath odour; facial edema; slurred speech; poor coordination; • a broad-based, foot-drop/slapping walk; visual disturbances such as blurred vision, bloodshot eyes; GI distress: nausea, vomiting, anorexia, diarrhoea; and/or insomnia.

19. Other signs…. • Other signs of problem drinking or of other substance abuse may include Interpersonal problems (family members, friends and co-workers), • changes in work habits (frequently late to work, leaving early), • problems in work performance, • changes in appearance (deterioration in dress and appearance), • significant mood and behavioural changes, and/or • frequent talk about drinking or drugs. These signs of distress can be the result of a number of different problems, and you should not assume that they are always substance abuse-related. Nearly all alcoholics have comorbid mental disorders, most commonly anxiety and mood disorders in woman and drug abuse and anti-social personality disorders in men (but men also get depressed and anxious). Depression and anxiety can precipitate heavy drinking, but can also be a result of alcohol abuse. It is important for primary health care practitioners to carefully screen all heavy drinkers for depression.

20. Withdrawal Symptoms • Lasts bet 6 to 12 hours after individual ceases to drink or decreases alcohol intake. • Features include; unsteadiness- delirium tremens(DTs); • Mild withdrawal lasts 24 to 36 hours after cessation of alcohol intake. • Features include intense anxiety; tremors; insomnia and excessive adrenergic symptoms(anxiety;trembling;sweating; shivering; palpitations; increased heart rate; dizziness)

21. Severe Withdrawal • Occurs more than 48 hours after cessation of alcohol cosumption. • Features include: disorentation; agitation and hallucinations along ithsevere trembling; tachycardia;tachypnea; hyperthermia and excessive sweating. • 25% with prolonged history of alcohol abuse have alcoholic hallucinations. • Symptoms incl. persecutory; auditory; most commonly visual and tactile hallucinations • Early stage recognizable- adv stage perceived real.

22. Management of Acute Intoxication • Acute effects of excessive amounts of AOD • Features include : recent intake; behavioural changes;impaired judgement; fluctuating mood; cognitivre impairment; interpersonal behaviour –hostility (DSMIV-TR) • FIND OUT: Blood alcohol level has peaked- when did they stop drinking? • Drinking at a steady rate or intake of large quantities before collapsing? If latter BAL will continue to increase- close supervision required

23. Management of Acute withdrawal • Monitor vital signs; hydraton and nutrtion • Supportive Care: reduced sensory stimuli; reality orientation; reassurance and positive encouragement. • Ample fluids by mouth/ IV fluids if signicately dehydrated; correct electrolyte imbalance • Thiamine

24. DAGGA (Ganja, insangu, zol, kif, bungi, marijuana, grass, herb…..) Proper name : Cannabissativa

25. DAGGA / CANNABIS Natural product (Cannabis sativa) Illegal drug ! Active chemical : THC Hallucinogenic – unpredictable Over 421 identified chemicals Dependence producing

26. DAGGA / CANNABIS Feelings of euphoria; relaxed and calm; loss of inhibitions; muscle coordination and concentration Increase heart rate; redness of the eyes; increased appetite Large quantities cause panic; hallucinations; restlessness and confusion/ perceptions Precipitates psychotic illness Stays in your body for 10 – 12 weeks Smoked drug – lung & organ damage

27. Symptoms of intoxication Red eyes (vasodilatation), tachycardia, postural hypotension, motor in-coordination, heightened sense of awareness, impaired estimation of time and distance, impaired judgment, increased appetite, dry mouth, various psychological reactions, such as euphoria, anxiety, perceptual distortions/ hallucinations, paranoid thoughts, impaired short term memory and other abnormalities. • Severe intoxication: Ataxia, sedation, slurred speech, poor concentration. • Chronic heavy use: Associated with long-term impairment in performance, especially of attention, memory, ability to process complex information (Amotivational Syndrome). • Medical complications:includeacute cardiac incidents, bronchitis and emphysema, lung cancer, immunosuppressant. • Withdrawal: Withdrawal is mild - agitation, tremor, insomnia few days only, “flashbacks” may occur. • Toxicology screen: Urine

28. Dagga Palm Stain : moretarthantobacco! GUESS WHAT THIS DOES TO YOUR LUNGS??

29. HEROIN (Smack, sugars, horse, Big H…China White;)

30. Heroin Paraphernalia

31. HEROIN / SUGARS/ Whoonga A semi-synthetic opiate- produced from dried milk of the opium poppy( mixed with lethal substances) Sedative / depressant Produce detached dreamy sensation; constriction of the pupil; vomiting; constipation Classically addictive Mental deterioration, weight loss, organ damage Convulsions, physical damage, coma, death Severe withdrawal <10% overcome heroine addiction

32. Whoonga/sugars • A mixture of low grade heroine and other additives like rat poison. • Highly addictive because: • The main ingredient is heroine which is highly addictive but can dull pain • The Strychnine ( in the rat poison) causes excruciating body pains; severe headaches; stomach pains and night sweats. • Vicious cycle as substances counter effect

34. Whoonga /sugars • A mixture of low grade heroine; cocaine and other additives like rat poison. • Brownish and usually sold in small plastic wrappers- lasts for about 45 min in system- 8 to 9 hits per day. Highly addictive because: • The main ingredient is heroine which is highly addictive but can dull pain • The Strychnine ( in the rat poison) causes excruciating body pains; severe headaches; stomach pains and night sweats. • Vicious cycle as substances counter effect

35. The effects of smoking ARVs remain doubtful; according to UKZN's Govender, drugs like ARVs are more easily absorbed into the body when taken orally rather than when smoked. When taken orally, the ARV Efavirenz does have initial side-effects including dizziness, double vision and vivid dreams, effects that have fuelled abuse of the drug in pill form in prisons. Senior lecturer at UKZN's department of therapeutics and medicines management, says it is unlikely smoking the drug would produce the same effects. "

36. COCAINE & CRACK (Snow, candy, blow, rocks….)

37. Snorting Cocaine Heading for a runny, crusty, bloody, numb nose

38. COCAINE / CRACK Stimulant Sniffed / smoked Long-term impact on brain Wakefulness/insomnia Loss of appetite Restlessness / involuntary movement High BP / Convulsions / Death Mental instability / paranoia

39. Cocaine & Tik :Enlarged Pupil

40. Methamphetamine (Tik, crystal, meth, ice, straw…… )

41. DRUGS & HIV / AIDS Careless drug use = careless sexual behaviour The person diagnosed as HIV positive may use drugs to : * Mediate Stress * Self-medicate * escape from reality

42. Crack cocaine – fastest growing drug of abuse in SA. Since 1994. Pivotal role of sex workers in spreading HIV has been well established in literature. Crack users reported having as larger volumes of clients than non-users. Crack increased the number of women on the street. Led to an increase demand for unsafe sex, -condom free; anal sex; client violence Rape on the increase- Increase transmission of HIV Crack Cocaine

43. To date little research has been done on the relationship between drug use and HIV transmission. Presumed minimal relationship on account of the known low rate of injecting drug use in the Country. 1991/1992 research shows that the primary injection drug used was Wellconal(synthetic opiate and antihistamine ). Major drugs currently abused in SA are smoked; including cannabis;Mandrax ;crack cocaine;and heroine. Heroin use has grown remarkably since 1994- sniffed; vaporised and inhaled(“chasing the dragon”) Is there a relationship between HIV and Drug abuse?

44. Dirty needles is not the only way drugs spread HIV. High correlation between crack and unprotected sexual activity. A large percentage of prostitutes consume crack, and a large percentage of crack abusers trade sex for their drugs. A very few of these transactions involve “ safe Sex “ practices. HOW DO DRUGS SPREAD HIV?

45. Addressing Substance Use Disorders in Primary Health Session Three

46. SUD – Learning Objectives Knowledge: • Identify the effects of SUD on your communities • Describe basic concepts common to all SUD • Explain the reasons for screening for SUD • List the steps of a brief intervention (BI) for SUD • Know about referral and community resources

47. SUD – Learning Objectives Skills: (clinicians) • Describe and perform simple screening tests • Confirm a positive screening test • Perform a brief intervention • Provide appropriate referral and monitoring

48. Who Uses Substances? Risky use 22% Harmful use, dependence 7% Abstinent or low risk use 70% Alcohol use among people 12 years and older – NSDUH,2004

49. Social & Economic Costs Social costs +++++ ++++++++++ ++ Harmful or dependent use Problems Many Some Few Hazardous or risky use Abstinence or low risk substance use

50. Basic Concepts of SUD • Substance use is learned behavior • Genetic and environmental factors important • Substance use disorders are on a continuum from low risk use to addiction • Hazardous use = risky drinking/drug use • Addiction (substance dependence) is a chronic brain disease