Substance abuse (PowerPoint) by nikeborome

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									Substance abuse

   Au Chui Kwan
        C2
     15/1/09
                  Content
• Classification of club-drugs
• Effects of commonly abused drugs
• Effects of club-drug on pregnancy
• Stages of change and motivation interviewing
• Approach and harm minimization in drug
  abusers
• Substance abuse in adolescents
• Screening guidelines for substance abuse and
  harm minimization in adolescents
                    Case
• Denise, aged 33, married, architect
• A patient you haven’t seen for few years
• Comes today for checkup after minor car
  accident on the weekend
                      Case
• When you asked how it happened
• She says probably due to ‘some pills’ she took
  at a party
• She tells you ‘I guess I was stupid to take drugs,
  you see, I’m pregnant and worried about my
  baby’
• She is ~ 8 weeks pregnant
                Question 1
• What are the common ‘club dugs’ or ‘party
  drugs’?
                 Club drugs
• Most common drug used in clubs / parties –
  alcohol
• Party drugs consist of a range of properties:
- Stimulants
- Depressant
- Hallucinogenic
               Club drugs
• Most widely used club drugs:
• 3,4-methylenedioxymethamphetamine
  (MDMA), also known as ecstasy 搖 頭 丸 、
  狂喜、忘我、E仔
• Ketamine K 仔 、 K 、 茄
• Gamma-hydroxybutyrate (GHB), street name:
  liquid ecstasy 迷姦藥
              MDMA (Ecstasy)
•   Originally developed in 1912
•   Patented as cough suppressant in 1956
•   A tranquilizer in 1960
•   Appetite suppressant in 1961
•   Mid 1980s, illegally produced for recreational
    use
             MDMA (Ecstasy)
• Derivatives of methamphetamine
• MDMA pills often impure and adulterated
  with caffeine, pseudoephedrine, lysergic acid
  diethylamide (LSD), MDEA/PMA
  (hallucinogens)
• Users can ingest tablets/ crush them to snort
  or dissolve for quicker action
                 Ketamine
• Derived from phencyclidine
• Short acting, dissociative anaesthetic in
  humans and animals
• Can be ingested, injected, snorted or smoked
  (when added to substances that can be
  smoked such as cannabis)
                     GHB
• Occurs naturally in brain
• Derivatives of inhibitory neurotransmitter
  gamma –aminobutyric acid (GABA)
• First synthesized in France 1960 as anaesthetic
• Produces dose dependent euphoria, dizziness
• In higher doses – hypotonia and amnesia
• GHB powder dissolved in water and ingested
• Unpleasant salty or soapy taste, often mixed
  with alcoholic drinks
               Question 2
• What are the main effects of common club
  drugs?
                    matching

• Alcohol               • Depressant
• Ecstasy               • Hallucinogen
• Amphetamine           • Stimulant
• Methamphetamine
• LSD
• Ketamine
• GHB (gamma hydroxyl
  butyrate)
• Cocaine
                    matching

• Alcohol               • Depressant
• Ecstasy               • Hallucinogen
• Amphetamine           • Stimulant
• Methamphetamine
• LSD
• Ketamine
• GHB (gamma hydroxyl
  butyrate)
• Cocaine
                    matching

• Alcohol               • Depressant
• Ecstasy               • Hallucinogen
• Amphetamine           • Stimulant
• Methamphetamine
• LSD
• Ketamine
• GHB (gamma hydroxyl
  butyrate)
• Cocaine
                    matching

• Alcohol               • Depressant
• Ecstasy               • Hallucinogen
• Amphetamine           • Stimulant
• Methamphetamine
• LSD
• Ketamine
• GHB (gamma hydroxyl
  butyrate)
• Cocaine
                    matching

• Alcohol               • Depressant
• Ecstasy               • Hallucinogen
• Amphetamine           • Stimulant
• Methamphetamine
• LSD
• Ketamine
• GHB (gamma hydroxyl
  butyrate)
• Cocaine
                    matching

• Alcohol               • Depressant
• Ecstasy               • Hallucinogen
• Amphetamine           • Stimulant
• Methamphetamine
• LSD
• Ketamine
• GHB (gamma hydroxyl
  butyrate)
• Cocaine
                    matching

• Alcohol               • Depressant
• Ecstasy               • Hallucinogen
• Amphetamine           • Stimulant
• Methamphetamine
• LSD
• Ketamine
• GHB (gamma hydroxyl
  butyrate)
• Cocaine
                    matching

• Alcohol               • Depressant
• Ecstasy               • Hallucinogen
• Amphetamine           • Stimulant
• Methamphetamine
• LSD
• Ketamine
• GHB (gamma hydroxyl
  butyrate)
• Cocaine
                     alcohol
•   Depressant
•   Why used: to relax and feel less inhibited
•   Effects of abuse:
-   Dependence
-   Liver damage
-   Toxic neurologic damage
                   ecstasy
• Street name: XTC, love drug, Adam, E
• 搖頭丸、狂喜、忘我、E仔
• Hallucinogen/stimulant
• Why used: feelings of intimacy, to enhance
  energy, sociability and sexual arousal
• Effects of abuse:
- Q3
Amphetamine, methamphetamine
•   Street name: yaba, ice
•   麻 古, 冰
•   Stimulant
•   Why used: feel full of energy and heighten senses
•   Effects of abuse:
-   Insomnia
-   Depression
-   Toxic psychosis
-   Loss of appetite
-   Heart and kidney failure
                       LSD
•   Street name: black sesame, fing ba
•   黑 芝 麻 、 FING 霸
•   Hallucinogen
•   Why used: to feel dissociated from
    environment
•   Effects of abuse:
-   Disoriented behavior
-   Impaired judgments
-   Nausea and vomiting
-   Increased pulse rate and elevated BP
                  Ketamine
• Street name: special K, vitamin K, Kit Kat
• K仔、K、茄
• Hallucinogen
• Why used: dreamy feeling/ detached
• Effects of abuse:
-Q3
                     GHB
• Street name: liquid ecstasy, liquid X, liquid E, G
• G 、 G 水 、 液 體 狂 喜 、 液 體 X 、 液 體E 、
  迷姦水
• Depressant
• Why used: uninhibited behaviour, mood
  elevation, relaxation. At high dose, CNS and
  CVS depressant
• Effects of abuse:
-Q3
                       Cocaine
•   Street name: coke, snow, crack可 卡 因 、 可 可 精
•   Stimulants
•   Why used: to feel full of energy and heighten senses
•   Effects of abuse:
-   Agitation
-   Feelings of persecution
-   Extra sensibility especially to noise
-   Damage to sensory tissues of nose
-   Impotence
-   Delirium
              Question 3
• What are the known harms with – MDMA,
  GHB, ketamine?
• What is the effects in pregnancy?
                  MDMA
• Principles effect on serotonin system
• Sympathetic nervous system overstimulation
   tachycardia, bruxism (tooth grinding), HT,
  arrhythmias, muscle tension
• Increased psychological arousal  hyperactive,
  flight of ideas, brief psychotic episode
• Hyperthermia and the associated ‘serotonin
  syndrome’
                  MDMA
• Serotonin syndrome  elevated core temp,
  rigidity, myoclonus, autonomic instability
• Results in end organ damage, rhabdomyolysis,
  acute renal failure, hepatic failure,
  coagulopathy
• MDMA  rises in anti diuretic hormone
• Heat from exertion during dancing coupled
  with MDMA induced hyperthermia lead to
  excessive water intake  severe hypoNa
                  MDMA
• hypoNa  confusion, delirium, paranoia ; may
  continue several weeks
• Many experience depression, consistent with
  serotonin depletion a few days after use
                   Ketamine
•   Side effects:
•   Bizarre hallucination
•   Dream like state, floating outside the body
•   Confusion
•   Delirium
•   flashbacks
•   Respiratory depression
                     GHB
• Overdose common as concentration of
  solution unknown
• Side effect: depression of respiratory and
  central nervous system, coma
          Effect of pregnancy
• Most club drug can cross placenta
• Effect on fetus largely unknown
• Many club drug adulterated with
  amphetamines  linked with
- Miscarriage
- Fetal abnormalities
- Premature labor
                Question 4
• How would you talk to Denise about her drug
  use?
            Stages of change
• Denise clearly motivated to ensure health of
  her baby
• The ‘stages of change’ model by Prochaska
  and Diclemente in 1982 – behaviour change
  when research smokers attempting to quit
• Model later used as framework to understand
  other behaviours such as alcohol abuse/
  dietary behaviour
              Stages of change
                      No intention to change
Precontemplation      Unaware of problems


                      Aware of problem
Contemplation         Ambivalent about ways to tackle it


                      Intent to take action in near future
Preparation           Attempt small changes


                      Modify behaviour to overcome problem
Action                Definitive commitment of time and
                      energy to this action

                      Consolidate gains made during action
Maintenance           Prevent relapse
             Stages of change
• Determine individual’s readiness to change
• Tailor interventions accordingly
• Efficient change in behaviour depends on
  doing the right thing (processes) at the right
  time (stages)
• at any point, there is risk of relapse to any of
  the earlier stage
            Stages of change
• Denise, contemplation/preparation stage of
  change
• At this stage, motivation interviewing
  described by Miller and Rollnick, aims to
  increase readiness for change by resolving
  ambivalence
• Controlled studies showed motivational
  interviewing as effective as cognitive
  behavioral techniques
       Motivation interviewing
• Interpersonal interactions
• Underlying messages of motivation
  interviewing :
- You want to learn about who the patient is,
  hear their story
- Your patient does not have to prove they are
  worthy of receiving help from you
         Motivation interviewing

• Underlying messages of motivation
  interviewing :
- You want to be a resource to them
- You don’t want to control them or their
  choices
- You want to be able to laugh with them and
  ‘enter’ their suffering
       Motivation interviewing
• Two acronyms useful in summarising
  motivation interviewing
• GRACE
• OARS
                   GRACE
• Gap stretching : increase awareness of
  discrepancy (gap) between how one wants
  thing to be VS how they are before change
• Roll with resistance
• Argue not
• Can do: support self efficacy and instilling
  hope
• Empathy: expressing empathy – a deep
  understanding of motives, feelings, thoughts
                     OARS
• Open ended questions: these establish
  rapport and gather information, eg ‘ how did
  you feel about taking drugs when pregnant?’
• Affirmations: verbal or non verbal cues eg ‘ it’s
  good you thought to come in to get a check up’
• Reflective listening: ‘it sounds to me that you
  don’t want to hurt your baby by taking drugs’
• Summarizing: ‘let me see if I understand what
  you’ve said’
                Questions 5
• What harm reduction strategies would you
  employ specifically for Denise and generally in
  dealing with drug use?
      harm reduction strategies
• Minimize potential dangers and risks to health
  of individual caused by their harmful
  behaviour
• Abstinence is one end of harm reduction
  spectrum, in view of Denise’s pregnancy,
  would be ideal
                     Denise
• Focus on positive thing she can do to improve
  the health of her baby
• Consider early referral to obstetrician or early
  USG to check for fetal abnormalities
• Use of drugs in early pregnancy carries a risk
  of harm but this is likely to be small in Denise’s
  case, clear message that her future actions
  can improve outcomes
             Harm reduction
• Where abstinence is not achievable at the
  moment, other strategies to reduce exposure
  to risk are worthy goals
• Harm reduction is not giving up, but a
  opportunity to create a therapeutic
  relationship which can help to reach the long
  term aim of abstinence
Harm minimisation and party drug
• Encourage non-use
• Avoid mixing drugs
• If try a drug for first time, use only small amount
• Avoid injecting drugs
• If at a dance, sip water rather than drink a lot at
  once, ie not more than 500mL/hr
• Watch for signs of overheating and dehydration
  eg headache or vomiting
• Go with a group and look after each other
     Substance abuse and harm minimization in adolescents, Basiliki
Lampropoulos, Australian Family Physician, Vol 36, (8) 577–672, August 2007
  Substances abuse in adolescent
• Adolescence – time when many people first
  experience drugs
• Protective factors:
- Good family communication
- Good family functioning
- Connectedness to adults, school
- Individual characteristics such as good
  communication skills, problem solving skills
  Substances abuse in adolescent
• Children of parents who have substances
  abuse are more likely to develop a substance
  use disorder themselves
  Substances abuse in adolescent
• Assessment/ identification of drug abuse
- Allow adolescent to see you on individual
  basis or with a support person if they prefer
- Explain confidentiality and its limit
- Use a framework for gaining psychosocial
  history from adolescent
- HEADSS, coined by Goldenring and Cohen
                  HEADSS
•   Home
•   Education and employment
•   Activities
•   Drugs
•   Sexuality
•   Suicide and depression
                  HEADSS
• Starts with least threatening areas (home)
• Ends with the most sensitive areas (suicide
  and depression)
• Framework not only identify drug use, but
  help identify comorbid issues, which may be
  contributing to substance abuse
 References: Team approach in the community-based
management of substance abusers – Resource book for
            the Beat Drugs Seminar 2008
Screening guidelines for substance
              abuse
• Behaviour patterns
• Late for home, staying outside for exceptionally long
  period ,run away from home
• Staying in own room, isolating from family members,
  secretive behaviour
• No appetite, sudden physical change, losing or
  gaining weight
• Personal hygiene pattern changed
• Antisocial behavior
Screening guidelines for substance
              abuse
• Emotional and psychological state
• Emotionally unstable , aggressive, agitated, or
  depressed
• Always put the blame on others
• Marked changes in psychological state
Screening guidelines for substance
              abuse
• Family systems
• Abrupt changes in family functioning
Screening guidelines for substance
              abuse
•   School/work
•   Abrupt changes in school functioning
•   Low concentration in class and in study
•   Bring a lot of money to school/work place
•   Asking money from classmate
•   Absent from work without reason
Screening guidelines for substance
              abuse
•   Leisure and recreation
•   Abrupt changes in hobbies or interests
•   No interests, or inert
•   Secretive communication with friend
•   Unexplained cash
•   Always asking for money /stealing money
•   Going to some high risk spot eg disco
Screening guidelines for substance
              abuse
• Presence of signs of drug use
• Strange equipment: pills. Needle
• Wear sunglasses inappropriately to hide
  dilated or constricted pupil
• Wear long sleeves inappropriately to hide
  needle mark
• Strange smell from boy
• Serious decayed teeth
 Harm minimisation in adolescent
• Stages of change and motivational
  enhancement
• Note that adolescent may be in different stage
  of change for different aspects of their
  substances abuse
• Eg, while adolescent may be pre-
  contemplative to cease opiate use, they may
  be contemplative or action oriented towards
  use of clean needles
 Harm minimisation in adolescent
Mange comorbid condition
• Often have depression, ADHD, homelessness
• Important to treat as closely connected to
  drug use
• Referral to local youth, counselling and mental
  health services useful
 Harm minimisation in adolescent
Family involvement
• Important to address parental substances abuse
• Parental factor can influence engagement of
   adolescent to treatment
– the higher the parental expectation for their
   child’s educational attainment, the more highly
   they rated their child’s externalizing behavior, the
   more engaged the adolescent with the treatment
                   References
• Check program – Substance abuse, November 2007
The Royal Australian College of General Practitioners
• Substance abuse and harm minimization in adolescents,
  Basiliki Lampropoulos, Australian Family Physician, Vol
  36, (8) 577–672, August 2007
• Clinical and psychosocial assessment of poly-drug
  abusers – Resource book for seminar for doctors to
  help beat drugs 2005
• Team approach in the community-based management
  of substance abusers – Resource book for the Beat
  Drugs Seminar 2008
Thank you

								
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