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Base Course Drug Use and Drug Use Disorders

Field test version-1.00 May 2012 DO NOT UPLOAD ON THE INTERNET. Base Course Drug Use and Drug Use Disorders. Contents (Drug Use). Introduction : Learning objectives Key actions Establish communication and build trust Conduct assessment Plan and start management

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Base Course Drug Use and Drug Use Disorders

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  1. Field test version-1.00 May 2012 DO NOT UPLOAD ON THE INTERNET Base CourseDrug Use and Drug Use Disorders

  2. Contents (Drug Use) • Introduction : • Learning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  3. Introduction (Pre session) • What legal and illegal drugs are commonly used in your community? • Why do people use drugs? • Should people be forced to have treatment? mhGAP-IG base course - field test version 1.00 – May 2012

  4. Drug use management is important • Drug use happens in almost all communities • Drug use is associated with substantial health and social problems • Drug use can lead to harm and dependence • Injecting drug users have high rates of HIV and Hepatitis C • Intensive cannabis use may result in psychotic disorders • Non-specialist clinicians can assess, manage or refer people with drug use problems • You can make a difference mhGAP-IG base course - field test version 1.00 – May 2012

  5. Drugs we will cover • Opioids • Benzodiazepines • Cannabis • Stimulants mhGAP-IG base course - field test version 1.00 – May 2012

  6. Opioids mhGAP-IG base course - field test version 1.00 – May 2012

  7. Signs of opioid use and withdrawal • Local names: [insert local names here] • Opioid intoxication: drowsiness, being “on the nod”, slow speech, small pupils, slow pulse, and depressed respiration • Chronic use: self-neglect, constipation, lack of sex drive, signs of injection, and complication of unsafe injection (hepatitis, HIV/AIDS). • Opioid withdrawal: anxiety, restlessness, dilated pupils, muscle aches, nausea and vomiting, diarrhea, abdominal cramps, headaches, raised pulse and blood pressure, yawning, runny nose and piloerection (“goosebumps”) • usually lasts 3-6 days mhGAP-IG base course - field test version 1.00 – May 2012

  8. Benzodiazepines mhGAP-IG base course - field test version 1.00 – May 2012

  9. Benzodiazepines • Local names: [insert local names here] • Benzodiazepine intoxication: sedation, slowed and slurred speech, depressed respiration • Chronic use is linked to impaired cognition and memory • Benzodiazepine withdrawal: anxiety and agitation, muscle cramps, abdominal cramps, raised pulse and blood pressure, insomnia, and (when severe) seizures and delirium • usually lasts one- two weeks mhGAP-IG base course - field test version 1.00 – May 2012

  10. Cannabis mhGAP-IG base course - field test version 1.00 – May 2012

  11. Cannabis • Local names: [insert local names here] • Cannabis intoxication: red conjunctivae, delayed responsiveness, and normal pupil size • Chronic use: self-neglect, poor hygiene, anxiety, and psychosis • Cannabis withdrawal: mood swings, anxiety and muscle cramps • usually lasts about one - two weeks mhGAP-IG base course - field test version 1.00 – May 2012

  12. Stimulants mhGAP-IG base course - field test version 1.00 – May 2012

  13. Stimulants • Local names: [insert local names here] • Includes amphetamines (speed, base, ice) and cocaine • Stimulant intoxication: hyperactivity, rapid speech and dilated pupils, raised pulse and blood pressure, arrhythmias, aggressive, erratic or violent behaviour • Chronic use: self-neglect, cachexia , impaired cognition, psychosis • Stimulant withdrawal: initially fatigue, increased appetite, irritability, depression and anxiety mhGAP-IG base course - field test version 1.00 – May 2012

  14. What causes drug withdrawal symptoms? • Our bodies and brains have mechanisms to minimize the impact of drug use on our ability to function • When we use sedating substances like opioids and benzodiazepines over a prolonged period of time, one of the ways our body adapts is to release endogenous stimulants like adrenaline to keep us alert • A common effect is increased tolerance to a substance which means that increased doses of the substance are needed to get the same sedative effect • When we stop taking the sedating substance, it takes about a week for our bodies to stop releasing the endogenous stimulants. In the meanwhile we experience the unbalanced effects of the endogenous stimulant. This is why the symptoms of sedative withdrawal are similar to stimulant intoxication. mhGAP-IG base course - field test version 1.00 – May 2012

  15. Contents (Drug Use) • Introduction • Learning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  16. Learning objectives • To be able to identify drug use problems in three categories • Hazardous use • Harmful use • Dependence • To be able to provide brief (motivational) interventions to reduce harmful/hazardous use • To be able to offer harm reduction strategies for people who inject drugs • To be able to provide regular follow up mhGAP-IG base course - field test version 1.00 – May 2012

  17. Contents (Drug Use) • Introduction • Learning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  18. Establish communication and build trust • What is different about communication and trust with a person with possible drug use compared to alcohol use • The issues are mostly the same • However, the added stigma and serious legal issues can make communication more challenging mhGAP-IG base course - field test version 1.00 – May 2012

  19. Establish communication and build trust • Identify the person's immediate expectations • For what reason has the person come to see you? • Consider that the person may be trying to manipulate you • Manage the person's expectations • Be honest about what you can and cannot do • Assess the impact of drug use on the person's life • How have their home and work life been affected mhGAP-IG base course - field test version 1.00 – May 2012

  20. Establish communication and build trust • Look for common ground • Explain that you both want to improve the person's health • Do not judge • Challenge misconceptions but avoid confrontation • Use good communication skills • Ask open questions • Remain neutral • Explain your understanding of the situation to the person • Always be honest • Expect that it will take multiple meetings to build trust • Honesty builds trust both ways. It can be useful to confirm aspects of the persons history with family members. mhGAP-IG base course - field test version 1.00 – May 2012

  21. Contents (Drug Use) • Introduction • Leaning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  22. Assessment of hazardous/harmful drug use mhGAP-IG base course - field test version 1.00 – May 2012

  23. Assessment of hazardous/harmful drug use What are examples of risks and harms from drug use that you should ask about? mhGAP-IG base course - field test version 1.00 – May 2012

  24. Assessment of drug dependence mhGAP-IG base course - field test version 1.00 – May 2012

  25. Assessment of drug dependence Drug dependence is pattern of symptoms that be clustered into different categories. Use Evidence of tolerance A physiological withdrawal state Loss of control Strong desire or sense of compulsion to take drugs Difficulties in controlling drug use Importance Progressive neglect of alternative pleasures or interests Drug use persisting despite harmful consequences Generally all three are present in dependence mhGAP-IG base course - field test version 1.00 – May 2012

  26. Examination and further investigation • You should always do a general physical examination • A physical exam should also assess for signs of drug use • Signs of injection • Pupils (relevant to most drugs) • Stigmata of liver disease (relevant to injecting drug use) • Cachexia (relevant to self-neglect) • Weight loss • Look for common health complications of injecting drug use • Evidence of HIV, Hepatitis B or C and TB infection mhGAP-IG base course - field test version 1.00 – May 2012

  27. Remember • Always try to get a sense whether the person with drug use problems is sober, intoxicated or in a state of withdrawal at time of the interview • If the person is intoxicated to the point that their behaviour is inappropriate, you may want to ask them to come back later. mhGAP-IG base course - field test version 1.00 – May 2012

  28. Contents (Drug Use) • Introduction • Leaning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  29. Management overview • Managing associated health problems • Brief (motivational) interventions • To facilitate cessation or reduction of drug use in people with harmful/hazardous use • To facilitate cessation or referral to treatment in people with drug dependence • Harm reduction strategies for any injecting drug users • Advice for breastfeeding mothers • In people who are dependent, referral for withdrawal management and dependence treatment mhGAP-IG base course - field test version 1.00 – May 2012

  30. A: Treatment of associated health problems • Common health problems • due to drug injection • HIV, hepatitis, skin infections, other infections • due to effects of the drugs • cannabis – anxiety, psychosis • stimulants – anxiety, psychosis • due to drug withdrawal • i.e. nausea, vomiting, muscle aches, pain, anxiety, insomnia • due to living conditions • TB, dental caries, STDs mhGAP-IG base course - field test version 1.00 – May 2012

  31. A: Treatment of associated health problems • Principles of management of health problems in drug users • if possible provide the treatment yourself rather than referring • consider vaccination against hepatitis A/B - no time like the present! • consider single high dose antibiotics rather than extended regimens • treatment in one place is generally better accepted than treatment in multiple places, i.e. for combined HIV, TB and opioid dependence • consider safety when prescribing psychoactive medication, arrange for supervised dosing (pharmacy or carer) or dispense frequent small amounts if necessary mhGAP-IG base course - field test version 1.00 – May 2012

  32. B: Brief Interventions for people with harmful/hazardous drug use • Do you remember the components of a brief intervention • Engage the person in a conversation about benefits/harms • Challenge misconceptions • Avoid arguing • Assess the impact of the drug use on the person's life • State clearly the recommendation to cut down or stop harmful use and your willingness to help • Encourage people to decide themselves if they need to change • If people are not ready to stop or reduce use, encourage them to come back to discuss further, perhaps with a family member or friend mhGAP-IG base course - field test version 1.00 – May 2012

  33. Strategies for Reducing and Stopping Use mhGAP-IG base course - field test version 1.00 – May 2012

  34. D. Advice for breastfeeding mothers • Strongly encourage breastfeeding mothers to avoid psychoactive drugs • cannabis has very high concentrations in breast milk • stimulants are neurotoxic • Refer to specialist care • In all cases, advise and support mothers with drug use disorders to breastfeed exclusively for at least the first 6 months, unless there is specialist advice not to breastfeed. mhGAP-IG base course - field test version 1.00 – May 2012

  35. Contents (Drug Use) • Introduction • Leaning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  36. Link with other services and supports • People with a drug use problem may benefit from • Self-help groups • Support from family, friends and community members • Other available community supports • Housing and employment services • Religious leaders • People with drug dependence may benefit from • Planned withdrawal services and dependence treatment • Rehabilitation services (i.e. drug free environments) • What is available in or near your community? mhGAP-IG base course - field test version 1.00 – May 2012

  37. Contents (Drug Use) • Introduction • Leaning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  38. Schedule follow-up • Treating a person with drug use can be a long process • It may take time for people to see their drug use as a problem • You must be patient • It is important to schedule regular follow up mhGAP-IG base course - field test version 1.00 – May 2012

  39. What would you do at follow up? • Re-assess drug use and its impact on the person’s life • Explore the person’s motivation to change their pattern of drug use • Continue to provide brief interventions • Provide or refer for dependence treatment if necessary mhGAP-IG base course - field test version 1.00 – May 2012

  40. Referring to a specialist • If the person continues to use despite brief interventions or shows signs of dependence, refer for further treatment • Successful referral is more likely when the person is motivated. Continue to discuss the perceived benefits and harms of the drug use with the person • If the person is not ready for further treatment, it may be better to ask the person to come back to discuss further, perhaps with a family member or friend mhGAP-IG base course - field test version 1.00 – May 2012

  41. Key messages • Health care providers can make a difference • Treat associated health conditions • Provide brief interventions to reduce hazardous/harmful substance use and to stop drug use in those with drug dependence. • Offer harm reduction strategies for people who inject drugs • Refer for further treatment if there is no improvement mhGAP-IG base course - field test version 1.00 – May 2012

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