Transcript Poly-drug use

Polydrug Use
Polydrug Use
Polydrug Use Defined
Polydrug use refers to:
“...the concurrent use of multiple drugs, or
the combining of drugs. It can occur in a
range of patterns and for a variety of
reasons, and may or may not involve drug
dependence.”
Swan & Ritter (2001, p. 1)
Polydrug Use
Polydrug Use
• Becomes a concern in terms of its relative risk
• Generally associated with hazardous or
harmful use of > 1 drug
• Appears to be ‘the norm’ amongst many drugusing groups
– many of whom rarely limit use to one drug,
or
– who use a primary drug along with a range
of other drugs
• Is highly prevalent among clients of drug
treatment services.
Polydrug Use
Patterns of Polydrug Use
Think about: context, patterns of use and
dependence
Common patterns of use include:
– using from multiple drug classes, but there
is no evidence of dependence on any one
class of drug
– dependence on one drug class, but use of
other drugs
– dependence on several drugs or classes of
drugs.
Polydrug Use
The Nature of Polydrug Use
Polydrug use depends on a range of factors:
– demographic and social
– availability and price
– desired effect and outcome of use
– previous experiences
(institutionalisation or previous medical
treatment appears to influence polydrug
use behaviours).
Polydrug Use
Reasons for Polydrug Use
• To enhance effects of other drugs
• To counteract effects of other drugs
• To provide a substitute for a preferred but
unavailable drug
• To conform to normative ways of using drugs
• To counteract the unpleasant effects of drugs
from different classes
• To self-manage the withdrawal from one drug
by using another.
Polydrug Use
Common Drug Interactions (1)
Drug combo
Degree of
interaction
Effects
BZDs + alcohol
+++
 sedation, intoxication, risk of OD
BZDs + opioids
+++
 sedation, intoxication, impairment,
risk of OD
common in MMT and elderly
Cannabis +
stimulants
+++
offsets cannabis sedation,  pulse
greater than either drug alone
Cannabis + alcohol
++
 intoxication and impairment
Polydrug Use
Common Drug Interactions (2)
Drug combo
Degree of
interaction
Effects
Opioids +
prescribed drugs
- to +++
various meds interact, precautions
needed for those which  respiratory
depression or sedation
Opioids +
antihistamines
+++
 intoxication, sedation and
impairment
Opioids +
stimulants
++
 intoxication  sedation
Polydrug Use
Harms from Polydrug Use
Intoxication, Regular Excessive Use and Dependence
Intoxication
Regular Excessive Use
accidents
overdose and poisoning
hangovers
absenteeism
high-risk behaviour
health
finances
relationships
work
I
R
D
Dependence
impaired control, drug centred behaviour
severe social or psychological problems, withdrawal
Polydrug Use
Service Provision and
Polydrug Use
• Engage into treatment
• Ensure effective collaboration
• Use Harm Reduction strategies
– prevention BBV, reduce use, crisis
intervention
• Multimodal treatment and cross referral
• Regular review.
Polydrug Use
Polydrug Assessment Issues (1)
• Conduct a systematic assessment of each drug class
– episodic use, time frame of at least 4 weeks, changing patterns
of use with changing availability, dependence (>1 drug?).
Include tobacco !
• Examine relationship between use of various drugs
– Is use of one drug related to the absence or use of another? Any
drug free periods? Use of one drug to modify withdrawal from
another?
• Identify drug use patterns, dependence and high-risk
using practices
– use of drugs from different classes +/- dependence on one or all.
Polydrug Use
Polydrug Assessment Issues (2)
Try to gain a sense of:
• patient’s reasons for choosing to use
particular drugs
• their multiple problems or concerns
• how their drug use and lifestyle affects
them (include both positive and negative
aspects)
• potential for withdrawal.
Polydrug Use
Screening
• WHO is developing a composite polydrug
screening instrument:
ASSIST: Alcohol, Smoking & Substance
Involvement Screening Tool
• To be used in primary health care settings to
help GPs decide whether the patient will
benefit most from:
– information
– brief intervention, or
– referral to specialised treatment.
Polydrug Use
Other Assessment Issues
• Allow adequate time (more time is needed
than for a single drug assessment)
• Obtain corroborating information
– e.g., friends / family, with consent
• Delay assessment if intoxicated – apply harm
reduction principles
• Consider your role and the practice staff in the
management of people with complex polydrug
use issues.
Polydrug Use
Key Issues in Treatment
• Harm mimimisation strategies a priority
• Opportunistic brief interventions are often all that
can be delivered
• Long-term treatment perspective is required –
few people abandon all drug use in the short
term
• Numbers of drugs used tend to  with age
• Patients may only be interested in dealing with
most immediate/problematic issues.
Polydrug Use
GPs and Management (1)
• Polydrug issues are complex, patients often
present in crisis. Clarify your role
• Consider a ‘shared care’ approach:
– AOD specialists (including mental health
services)
– relevant local health and welfare agencies
– crisis intervention services
– families and other peer support groups
(esp. useful with young people).
Polydrug Use
GPs and Management (2)
• Develop ongoing therapeutic relationship
(BI, counselling etc.); encourage return
despite possible frequent non-attendance
• With patient, identify which (most harmful)
drug to tackle first for stabilisation or
withdrawal
• Polydrug withdrawal is complex – work with
(or refer to) specialists
• Ensure contact and liaison with other AOD
services.
Polydrug Use
Who is Suitable for Counselling?
• Counselling is suitable for those who:
– self-identify as polydrug users
– are subject to court orders
– are pressured into treatment by employers,
family or friends
• Counselling is not suitable for those who:
– are actively psychotic
– have significant cognitive impairment or
intellectual impairment
– are grossly intoxicated.
Polydrug Use
A Final Comment
If the young polydrug user can be kept
alive, and free of disease, there is a
natural tendency towards eventually
moderating or giving up drug use.
Treatment may provide ‘a nudge along
the natural pathway of recovery’.
Polydrug Use