Participant Manual
Module 5
Managing Non-Opioid Drug Dependence Treatment and Care for HIV-Positive Injecting Drug Users
Regional Office for South-East Asia
Family Health International
Module 5
Managing non-opioid drug dependence
Participant Manual
2007
The Association of Southeast Asian Nations (ASEAN) was established on 8 August 1967. The Member States of theAssociation are Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand and Viet Nam. The ASEAN Secretariat is based in Jakarta, Indonesia. For inquiries, contact The Public Affairs Office, The ASEAN Secretariat, 70A Jalan Sisingamangaraja, Jakarta 12110, Indonesia, Phone: (62 21) 724-3372, 726-2991, Fax: (62 21) 739-8234, 724-3504. E-mail: public@aseansec.org. General information on ASEAN appears on-line at the ASEAN Website: www.aseansec.org. Catalogue-in-Publication Data Treatment and Care for HIV-Positive Injecting Drug Users Jakarta: ASEAN Secretariat, December 2007 616.9792 1. ASEAN – USAID 2. HIV – Drugs – Modules ISBN 978-979-3496-63-4 (NLM classification: 503.6)
This publication is available on the internet at www.aseansec.org, www.fhi.org and www.searo.who.int/hiv-aids publications. Copies may be requested from: The ASEAN Secretariat, 70A, Jl. Sisingamangaraja, Jakarta 12110, Indonesia. e-mail: public@aseansec.org and Family Health International, Asia/Pacific Regional Office, 19th Floor, Tower 3, Sindhorn Building, 130–132 Wireless Road, Lumpini, Phatumwan, Bangkok 10330, Thailand, e-mail: sunee@fhibkk.org and HIV Unit, Department of Communicable Diseases, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110 002, India, e-mail: hiv@searo.who.int Module 1: Drug use and HIV in Asia: participant manual Module 2: Comprehensive services for injecting drug users – participant manual Module 3: Initial patient assessment – participant manual Module 4: Managing opioid dependence – participant manual Module 6: Managing ART in injecting drug users – participant manual Module 7: Adherence counselling for injecting drug users – participant manual Module 8: Drug interactions – participant manual Module 9: Management of coinfections in HIV-positive injecting drug users – participant manual Module 10: Managing pain in HIV-infected injecting drug users – participant manual Module 11: Psychiatric illness, psychosocial care and sexual health – participant manual Module 12: Continuing medical education – participant manual Trainer manual: Treatment and care for HIV-positive injecting drug users © ASEAN Secretariat 2007
All rights reserved. The text of this publication may be freely quoted or reprinted with proper acknowledgment.
Typesetting and Design: Macro Graphics Pvt. Ltd. Printed in India
Contents Abbreviations and acronyms.......................................................................................................................................iv Module 5: Managing non-opioid drug dependence............................................................................................1 Overview................................................................................................................................................................................ 1 Drugs and their effects..................................................................................................................................................... 2 Amphetamine use.............................................................................................................................................................. 2 Drug dependence: a chronic “health impairment”................................................................................................. 2 Treatment interventions.................................................................................................................................................. 3 Co-morbid mental illness................................................................................................................................................. 6 Treatment of non-opioid drug use............................................................................................................................... 6 Summary................................................................................................................................................................................ 7 References and recommended reading..................................................................................................................... 7 Exercise 5: Case studies..................................................................................................................................................... 8
Annex 1: PowerPoint presentation 5: Managing non-opioid drug dependence.................................... 10
Abbreviations and acronyms AIDS ART ARV ASEAN ATS BP CBT CDC ECG FHI HIV ICD-10 IDUs LSD NGO acquired immunodeficiency syndrome antiretroviral therapy antiretroviral Association of Southeast Asian Nations amphetamine-type stimulants blood pressure cognitive–behavioural therapy Centers for Disease Control and Prevention (US Government) electrocardiogram Family Health International human immunodeficiency virus International Classification of Disease, 10th revision injecting drug users lysergic acid diethylamide nongovernmental organization
PLWHA people living with HIV and AIDS OST USAID WHO opioid substitution therapy United States Agency for International Development World Health Organization
Module
5 Overview
Managing non-opioid drug dependence
F º
Oobjectives: By the end of the session participants will: Be familiar with common amphetamine-type stimulants (ATS) and their patterns of use in Asia Be familiar with symptoms of non-opioid dependence and medications used to deal with these symptoms Be able to describe relapse prevention approaches Time to complete session: 1 hour 45 minutes Session content: Drugs and their effects Amphetamine use Drug dependence: a chronic “health impairment” Treatment interventions Co-morbid mental illness Treatment of non-opioid drug use Training materials:
4
PowerPoint presentation 5: Managing non-opioid drug dependence Exercise 5: Case studies 1 and 2
Managing non-opioid drug dependence
Drugs and their effects To provide the background to this module it is important to refresh your understanding of the symptoms of various drugs used and the medications necessary to treat them. 1. Stimulants: This group includes coffee, nicotine, cocaine, amphetamines and Ecstasy. The physiological effects of use are arousal, exhilaration, anxiety, a feeling of well-being, decreased appetite, weight loss, indifference to pain and fatigue. In addition, there may be irritability, irrationality, unpredictability, restlessness, panic, paranoia, decreased or increased concentration, dilated pupils, sexual arousal or feelings of affection. Often, there are problematic feelings of strength, prowess or violence. Rarely, there is myocardial ischaemia or infarction, cardiac arrest or stroke.
2. Sedatives: Alcohol, cannabis, benzodiazepines, inhalants and opioids Physiological effects include euphoria, disinhibition, a feeling of calmness and well-being, reduced anxiety, stress and pain, decreased concentration and coordination, with sedation, drowsiness and respiratory suppression. The pupils may be dilated or constricted, appetite diminished, nausea, decreased motivation, paranoia, aggressiveness or hallucinations. Rarely, some of the drugs in this group can cause drug-induced psychosis.
3. Hallucinogens: Lysergic acid diethylamide (LSD), cannabis, Ecstasy, magic mushrooms This group produces a variety of intense sensory experiences with mixing of the senses, distortion of the assessment of time and space, visual hallucinations, a rapid pulse, dilated pupils, nausea and hypertension. Variably, this group of drugs produces relaxation, a feeling of well-being, paranoia, confusion, anxiety, loss of appetite and rarely psychosis.
Amphetamine use The use of amphetamines is initially characterized by functional feelings of energy, enthusiasm, productivity and particularly euphoria. With repeated use (and higher doses) there is an increasing search for that early, intense euphoria and an increasingly disturbed sleep cycle. With repeated amphetamine use, stereotyped, repetitive activity develops around the drug use itself to the exclusion of other activities. Progression to higher dose binges may last for days with sleep deprivation and psychopathology that includes hallucinations, paranoia, anxiety or overt psychosis. These periods of prolonged use (“binges”) are eventually followed by exhaustion and withdrawal dysphoria, with hypersomnia and depression (even suicidality).
Drug dependence: a chronic “health impairment” Amphetamine abuse can lead to dependence, which is a typical, chronic, relapsing condition, characterized by exacerbations and remissions, with a number of predisposing conditions and a cycle of evolution and resolution.
Participant Manual
Managing non-opioid drug dependence
Relapse following periods of abstinence appears closely related to geographical and social cues. Criteria for dependence syndrome: See ICD-10, chapter 5. A diagnosis of an amphetamine dependence syndrome can be made if three or more of the following have been present together at some time during the previous year: Desire or sense of compulsion to take the substance Difficulty in controlling substance-taking behaviour (amounts) Tolerance Withdrawal Neglect of alternative pleasures Substance use despite clear evidence of overtly harmful consequences.
Amphetamine-related harms Even short-term or a single use of amphetamines can generate paranoia, irritability, anger and violence. Recurrent use is associated with weight loss, anxiety and insomnia. Associated with prolonged use are (often violent) crime, theft, drug syndicates and consequent legal problems and imprisonment. Suicide, accidental death, trauma and murder are much more common in an amphetamine or cocaine subculture. Sexual risk is markedly increased by transition to sex work or participating in unsafe and prolonged sex. There is also a predictable decline in financial situation resulting in poverty, with considerable stigma, social and legal problems. Rarely, the acute use of amphetamines (particularly IV) can lead to intracerebral haemorrhage, myocardial ischaemia or psychosis. In addition to the harms of the drug use, there are the harms associated with infection due to injection use: bloodborne viral infections from shared equipment (hepatitis, HIV), systemic contamination (endocarditis, fungal abscess, osteomyelitis), and local infection from poor hygiene or frequent injection.
Problematic amphetamine use Problematic use, as distinct from recreational, functional or dependent drug use, is associated with weight loss, dysfunctional relationships, domestic violence, anxiety, aggression, paranoia, sleep deprivation, insomnia and even a sore throat from smoking methamphetamines. In addition, interruption of work after heavy weekend binges is common. The use of sedatives such as alcohol, benzodiazepines, cannabis or heroin to “come down” from an amphetamine binge can generate severe problems of its own.
Treatment interventions Acute intoxication The interventions available for acute intoxication are largely social and supportive but include the provision of a non-stimulating environment, support, reassurance and the prevention of harm to users and others. This is best provided in a safe space to “chill out” , avoid confrontation and encourage the support of family or sober friends.
Module 5
Managing non-opioid drug dependence
Medical interventions include the monitoring of fluid (and food) intake and output, benzodiazepines for severe agitation and anxiety (if not controlled by the environment), and occasionally antipsychotics (haloperidol/chlorpromazine, risperidone) if agitation is severe or associated with psychotic symptoms.
Complicated intoxication This usually presents as an acutely disturbed mental state (delirium/paranoia) associated with nausea, vomiting, sweating, malaise or pain (chest/abdominal). The first aid or emergency physician should explore the recent history of drug use from the patient, friends and family, correct the fluid and electrolyte status, monitor the ECG, blood pressure (BP) and look for signs of hypo - or hyperthermia. The patient may require cooling and sedation for referral to hospital or intensive care.
Amphetamine withdrawal This difficult syndrome usually lasts 2–4 weeks though the acute “crash” only lasts for 1–4 days and is characterized by fatigue and exhaustion, hunger, emotional lability, overwhelming desire to sleep (but may sleep poorly), and craving. This syndrome is then followed by strong urges to use amphetamines, which may increase over the following six weeks with disrupted sleep, headache and bodyache, increased appetite, irritability and paranoia. The dependence and withdrawal syndromes should be treated sparingly and symptomatically with great care shown if benzodiazepines are used. Return to normal occurs 1–3 months after cessation of amphetamine use, though the craving persists for years.
Non-pharmacological management of withdrawal In addition to the symptomatic treatment outlined above, management of the environment is probably more important with the provision of safe, secure surroundings, access to “useful” family and other supports, instruction in relaxation and sleep advice, with contingency management and other drug counselling. An inpatient facility or detoxification centre can be the site for this “care” , particularly in the presence of polydrug dependence, psychiatric complications, absence of social supports or a previous complicated withdrawal. It is to be noted that inpatient treatment of withdrawal with tapered reduction of amphetamine use is no more effective than doing nothing.
Relapse prevention Interventions that have been shown to have some positive impact on relapse to amphetamine use are brief interventions and motivational interviewing, generic drug counselling, cognitive –behavioural therapy, cue exposure and contingency management. In addition, behavioural approaches using skills development, vocational training, recreation groups, family therapy and community or cultural reconnection all add to the above. Treatment of any underlying psychopathology, particularly mood disorder, is vital for effective relapse prevention.
Participant Manual
Managing non-opioid drug dependence
Harm reduction counselling and referral for peer group support, residential rehabilitation or to Narcotics Anonymous may be appropriate.
Ineffective therapies It is important to note that some programmes have not been found to be any better than placebo. These include acupuncture, hypnosis, Antabuse ®, naltrexone, antidepressants (in the absence of clinical depression), the MATRIX ® programme, Narconon ® or Crimonon ® (Scientology), imprisonment or incarceration for rehabilitation.
Benzodiazepine dependence Once established, dependence on benzodiazepines is another difficult syndrome with no shortterm withdrawal treatment available. The recommended treatment is a long, slow reduction over four or more months by transferring the patient to long-acting daily dispensed benzodiazepine, reducing the dose every two weeks by a maximum of 10% per day. Long-term maintenance is occasionally necessary, though great care must be taken if opiate or alcohol dependence are also present.
Cannabis dependence The identification of cannabis dependence is still a controversial syndrome. Withdrawal symptoms are characterized by insomnia, night sweats, irritability and mood swings, and has a prolonged duration of 10–14 days. The experience of withdrawal can be assisted by the judicious use of benzodiazepines with or without the use of mood-stabilizing anticonvulsants. It is very often necessary to undertake cannabis withdrawal in the inpatient setting to successfully achieve the prolonged abstinence necessary to complete the process. In general, with problematic cannabis use, the implementation of a harm reduction approach with generic counselling using cognitive–behavioural therapy and supportive approaches is the most effective intervention. There is good evidence for the use of peer support or counselling performed in groups. A number of well-researched step-wise programmed interventions are available for groups and individuals.
Alcohol dependence Alcohol dependence is characterized by the following: salience of drinking, narrowing repertoire, craving for alcohol, loss of control, tolerance, abstinence syndrome and relapse following abstinence. It is a brain disorder. With repeated alcohol exposure, long-lasting changes occur in the receptors and in the series of chemical interactions they signal. Neuroadaptation involves changes at many different levels, from the genetically directed production of critical proteins to physical changes in the structure of the cells on both sides of the synapse – that is, both the signalling and the receiving cell. Neuroadaptation is linked to tolerance, withdrawal and craving. Alcohol withdrawal can be effectively managed with long half-life benzodiazepines such as diazepam. Severe withdrawal states characterized by delirium, seizures, and severe agitation need to be referred to the drug treatment services or general medical services for management. Thiamine should be given intramuscularly in chronically dependent patients as it is more effectively absorbed by this route in the early stage of withdrawal. Maintenance of alcohol abstinence or reduced use can be enhanced by the use of
Module 5
Managing non-opioid drug dependence
naltrexone or acamprosate, both of which reduce the cravings associated with withdrawal from alcohol dependence. Although naltrexone is more effective in reducing relapse to alcohol use, it cannot be used during opioid substitution therapy (OST) nor should it be used in heroin users as it blocks the effects of opiates. In these cases, acamprosate should be used. Pharmacotherapy to reduce relapse should be given in conjunction with psychosocial interventions and support. By instituting pharmacotherapy the clinician can effectively establish a therapeutic alliance with the patient. Psychosocial interventions will facilitate better adherence to treatment.
Co-morbid mental illness Problematic drug use is much more common in those with mental health problems such as schizophrenia, depression, personality disorder, bipolar disorder and anxiety disorder. The prevalence of one with the other occurs is about 45–55% of patients, with half of all problematic substance users having a co-morbid mental health condition. The disability experienced from the combination of mental health problems and problematic drug use is significantly higher than either alone, with poorer treatment outcomes. The greatest health impact is on those who are drug users and have mental illness; however, cigarette smoking has the greatest impact, with over 60% of smokers dying from its use. The co-existent morbidity from drug use and mental illness is usually underserviced, with the addition of complex social and legal issues. The increased risk of suicide, violence and “difficult behaviour” in this group of patients and the high rate of relapse of either condition makes their treatment unattractive to many services.
Management issues for co-morbidity The management of a service for drug users with a co-morbid mental health problem needs to assess them using a combination of self-reported and collateral information from friends, family and other professionals. Laboratory investigations and questionnaires can be useful in screening for drug use in those with mental illness and for mental illness in drug users, as well as their readiness to embark on behaviour change. The integration of treatment services with parallel, sequential or integrated models of care needs to address cross-referral, access to care and the difficulty of follow up in this group. The key issues for care outcomes seem to be fostering engagement and motivation, providing motivational interviewing and cognitive–behavioural therapy, and medications for psychosis, depression and anxiety. A proactive (assertive) outreach component has been shown to be of benefit.
Treatment of non-opioid drug use Non-opioid drug use is a growing issue in Asia for which no simple, effective pharmacological treatment or psychological therapies are available. Methamphetamine use and dependence is the most problematic of the non-opioid drugs used in the region, with demonstrated effectiveness of the use of peer group support, community reconnection and employment strategies. There is little evidence for the effectiveness of residential or other complex therapeutic programmes. Co-morbid mental illness is a complex condition that requires recognition and additional treatment using engagement, user-friendly services and assertive outreach.
Participant Manual
Managing non-opioid drug dependence
Summary For this common regional problem, it is necessary to become familiar with the symptoms of nonopioid dependence, the medications used to deal with these symptoms, and be aware of effective relapse prevention approaches.
References and recommended reading Australian National Council on Drugs. Evidence supporting treatment: the effectiveness of interventions for illicit drug use. Woden, Australia, Australian National Council on Drugs, 2001 (http:// www.ancd.org.au/publications/pdf/rp3_evidence_supporting.pdf ). Department of Health and Aging. Management of patients with psychostimulants use problems: guidelines for general practitioners. Canberra, Department of Health and Aging, Australian Government, 2004 (http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing. nsf/content/AC11DD6A037F9ECFCA25717D00811748/$File/psychostimnts_gp.pdf ). Department of Health and Aging. Models of intervention and care for psychostimulant users. Canberra, Department of Health and Aging, Australian Government, 2004 (http://www.health.gov. au/internet/wcms/Publishing.nsf/Content/health-pubhlth-publicat-document-mono51-cnt.htm). National Drug and Alcohol Research Centre. Co-morbid mental disorders and substance use disorders: epidemiology, prevention and treatment. Sydney, Australia, National Drug and Alcohol Research Centre, University of New South Wales, 2003 (http://www.health.gov.au/internet/wcms/Publishing.nsf/ Content/health-pubhlth-publicat-document-mono_comorbid-cnt.htm/$FILE/mono_comorbid.pdf). World Health Organization. Amphetamine-type stimulants: a report for the WHO meeting on amphetamines, MDMA and other psychostimulants, Geneva 1996. Geneva, WHO, 1997.
Module 5
Managing non-opioid drug dependence
Exercise 5.1 Case Studies Please discuss these cases in groups of two or three for about 15 minutes: Identify the features of drug use. Identify the characteristic features of dependence. Provide feedback to the group on your insights.
Case study 1 Ronny, a 26-year-old crystal methamphetamine (shabu) smoker, presents to a new health centre doctor inquiring about treatment. Ronny has attended this clinic occasionally over the past two years, obtaining medication for outpatient drug withdrawal several times. On one occasion one year ago, he entered inpatient psychiatric treatment for “drug-induced psychosis”; however, he discharged himself after two weeks. He last attended the health centre two months ago for an outpatient withdrawal using benzodiazepines. Ronny describes first smoking methamphetamines five years ago and first regular smoking use three years ago. He states he is currently smoking shabu on average three times a day, and spends approximately US$ 10 each day. He states that he remained “clean” for approximately three weeks after the last withdrawal, then recommenced use again – escalating to this current level of use about one month ago. This is a recurring pattern for Ronny, with relapses soon after each withdrawal attempt. Ronny smokes cigarettes but describes no other regular drug use. He has no other significant medical conditions. He lives in the family house with his brother who also uses methamphetamines. He is employed in the family import/export business and his parents live in Australia. He is married but his wife has moved with their young baby to her parent’s house more than 200 km away. He maintains regular contact with his sister, who has encouraged him to enter treatment. The doctor is encouraged that finally Ronny is thinking more about longer-term treatment than neraly another withdrawal, as he had been suggesting for a long time that he enter some form of longer-term treatment. In the past Ronny has been reticent about counselling and unprepared to enter long-term rehabilitation. 1. What are the characteristic features of opioid dependence in Ronny?
2.
What are the possible harms?
3.
Where is he located in the cycle of change or motivation?
Participant Manual
Managing non-opioid drug dependence
Case study 2 Aung is a 24-year-old labourer and methamphetamine user with a three-year history of regular oral methamphetamine consumption. He presents to his doctor with his pregnant wife seeking “help” about a badly infected cut on his forearm from a knife fight. He explains that he suspected his neighbour of plotting to have him arrested and started a fight. The doctor treats the local infection with a prescription for antibiotics, and recommends to the patient to cease his amphetamine use. Aung states that he has it under control and is reluctant to consider stopping, but is prepared to “go along” with the doctor, and offers no objection when the doctor makes an appointment for him to attend the local drug treatment centre in four days for an assessment. A week later, Aung presents again with his wife to the doctor seeking another prescription for antibiotics as the infection has not entirely resolved. It is clear that Aung has continued his drug use, and that he had not kept his appointment with the drug treatment centre withdrawal unit. The doctor is frustrated, but he does not express his disappointment to Aung, and he provides another prescription for antibiotics. He concludes the consultation with an offer for Aung and his wife to come back again to see him if he wants treatment in the future. Six weeks later Aung presents again, still somewhat ambivalent about stopping his drug use altogether, but his methamphetamine use has escalated in recent weeks. He is very unhappy and has serious financial problems. His wife has returned to her family and he may lose his job. Going through the options, Aung agrees that he cannot keep using methamphetamine as he has been doing and that things seem out of control. The doctor again suggests an inpatient detoxification programme but Aung agrees to withdrawal medication as he does not want to go to an inpatient unit because he has to work. He begins an outpatient withdrawal regimen with the doctor, who also engages a local drug treatment NGO to provide some support and counselling during and after the withdrawal. 1. What are the characteristic features of amphetamine dependence in Aung?
2.
What are all the possible harms he may experience?
3.
What can be suggested to reduce these harms?
4.
Where is he located in the cycle of change or motivation?
5.
What do you think are the treatment options for him?
Module 5
Annex 1
presentation 5: Managing non-opioid drug dependence Session objectives By the end of the session the participants will:
Managing non-opioid drug dependence Drug use, dependence and treatment
Be familiar with the symptoms of non-opioid use and dependence, and medications used to deal with these symptoms Be able to describe relapse prevention approaches
Injecting in Asia
Amphetamine use
Not all drugs injected in Asia are opioids. The main non-opioid drugs injected in Asia are amphetamine-type stimulants (ATS).
Early use – energy, enthusiasm, productivity
+ euphoria Increasing search for intense euphoria Very stereotyped, repetitive activity around drug use Exclusion of other activities Sleep deprivation and psychopathology Hallucinations, paranoia, anxiety or overt psychosis Followed by exhaustion and withdrawal dysphoria Hypersomnia and depression (even suicidality)
With repeated use (and higher doses)
Progression to high-dose binges lasting for days
Dependence is a typical chronic “health impairment”
Criteria for dependence syndrome Summary ICD-10 A diagnosis of dependence syndrome can be made if three or more of the following have been present together at some time during the previous year: Desire or sense of compulsion to take the substance Difficulty in controlling substance-taking behaviour (amounts) Tolerance Withdrawal Neglect of alternative pleasures Substance use despite clear evidence of overtly harmful consequences
Drug dependence is a chronic relapsing condition characterized by exacerbations and remissions with a number of predisposing conditions and a cycle of evolution and resolution “Life cycle” appears to be predetermined by the drug itself: Examples : heroin 10–15 years amphetamines 5 years cigarettes >40 years
Relapse is closely related to geographical and social cues
Managing non-opioid drug dependence
11
Activity 1: case studies
Activity 1 – case study: Ronny
Please discuss these cases in groups of two or three for about 15 minutes:
What are the characteristic features of opioid dependence in Ronny? What are the possible harms? Where is he located in the cycle of change or motivation?
Identify the features of drug use Identify the characteristic features of dependence Provide feedback to the group on your insights
Activity 1 – case study: Aung
Activity 2: amphetaminerelated harms
What are the characteristic features of amphetamine dependence in Aung? What are all the possible harms he is experiencing? What can be suggested to reduce the harms? Where does he sit in the cycle of change or motivation? What do you think are the treatment options for him?
In small groups of three or four list the potential harms associated with amphetamine use
Spend ten minutes brainstorming together Then provide feedback to the larger group Perhaps there will be some time to discuss the causes of harm and actions to mitigate them
May be helpful to break down the potential harms into biological, psychological, social and economic
Activity 3: amphetaminerelated harms
Problematic amphetamine use
Paranoia, irritability, anger, violence Weight loss, anxiety, insomnia Crime, theft, imprisonment, drug syndicates Suicide, accidental death, murder Sex work, unsafe prolonged sex Financial, poverty, community, legal, stigma Stroke, heart attack, psychosis Harms associated with injection use:
Weight loss Dysfunctional relationships Domestic violence Sore throat from smoking methamphetamines Anxiety, aggression, paranoia Sleep deprivation, insomnia Interruption in work after weekend binges Use of sedatives to “come down”
Infection Bloodborne infections from shared equipment
– hepatitis, HIV Systemic contamination infections – endocarditis, fungal abscess, osteomyelitis Local from poor hygiene and frequent injection
Alcohol, benzodiazepines, cannabis, heroin
Annex 1
12
Managing non-opioid drug dependence
Treatment interventions
Complicated intoxication
Acute intoxication
Provision of non-stimulating environment Provision of support and reassurance Prevent harm to self and others Provision of safe space to “chill”
Acute:
Disturbed mental state (delirium/paranoia) Nausea, vomiting Sweating, malaise, chest/abdominal pain
Avoid confrontation Encourage family support Monitor fluid (and food) intake and output Benzodiazepines if agitation and anxiety not controlled Antipsychotics (haloperidol/chlorpromazine) if agitation or anxiety not contained or psychotic symptoms present
Explore recent history of drug use – friends / family Correct fluids and electrolytes Monitor ECG and BP Sedate for extreme agitation Monitor for hypo-/hyperthermia – may need cooling Refer to hospital or intensive care
Amphetamine withdrawal
Lasts 2–4 weeks but “crash” only for 1–4 days:
Non-pharmacological management of withdrawal
Fatigue and exhaustion Hunger Emotional irritability Overwhelming desire to sleep but may sleep poorly Craving Increase over the next six weeks
Environment management
Followed by strong urges to use
Safe situation Family and other support Relaxation and sleep advice Contingency management counselling Polydrug dependence Psychiatric complications Absence of social supports Previous complicated withdrawal
Inpatient/detoxification centre for “care”
Disrupted sleep Headache and bodyache Increased appetite Irritability and paranoia
Treat symptomatically – great care with benzodiazepines
Return to normal 1–3 months after cessation of use
Note: Inpatient treatment of withdrawal and tapered amphetamine withdrawal is as effective as doing nothing
Relapse prevention
Ineffective therapies
Brief interventions/motivational interviewing Generic drug counselling Cognitive–behavioural therapies Cue exposure/contingency management Behavioural approaches using:
Some programmes have not been found to be any better than placebo:
Skills development Vocational training Recreation Family therapy and community reconnection
Harm reduction counselling and peer group support Treatment of underlying psychopathology Residential rehabilitation/Narcotics Anonymous
Acupuncture Antabuse ® Naltrexone Antidepressants (in the absence of clinical depression) MATRIX ® programme Narconon ®/Crimonon ® (Scientology) Imprisonment/incarceration for rehabilitation Hypnotherapy
Participant Manual
Managing non-opioid drug dependence
13
Benzodiazepine dependence
Cannabis dependence
No short-term withdrawal treatment available
Controversial syndrome
Recommended long, slow reduction over 4+ months Transfer to long-acting benzodiazepine Dispensed daily Dose reduced every two weeks by a maximum of 10% per day Long-term maintenance occasionally necessary Great care needed in treatment if opiate or alcohol dependence also present
Characterized by: Insomnia Irritability and mood swings Assisted with judicious use of benzodiazepines and/or anticonvulsants Often needs to be treated as on inpatient for successful completion
Prolonged withdrawal over 10–14 days
Harm reduction Generic counselling with CBT most effective
Can be performed in groups or as individuals A number of researched step-wise programmes available
Alcohol dependence: a brain disorder
Alcohol dependence: withdrawal services
With repeated alcohol exposure, long-lasting changes occur in receptors and in the series of chemical interactions they signal. Neuroadaptation involves changes at many different levels, from the genetically directed production of critical proteins to physical changes in the structure of the cells on both sides of the synapse – that is, both the signalling and the receiving cell. Neuroadapatation is linked to tolerance, withdrawal and craving.
Planned withdrawal management is ideal. Alcohol withdrawal can be effectively managed with long half-life benzodiazepines such as diazepam. Severe withdrawal states characterized by delirium, seizures, severe agitation need to be referred to drug treatment services or general medical services for management. Thiamine should be given in chronically dependent patients.
Source: NIAAA, 2004.
Alcohol dependence: medications
Alcohol dependence
Naltrexone and acamprosate are two medications that act on the receptor systems in the brain on which alcohol is known to have an impact. Naltrexone blocks some of alcohol’s rewarding effects. Acamprosate’s precise mechanism of action is not yet known, but it is thought to affect the activity of the neurotransmitter glutamate.
Genetic as well as environmental influences contribute to alcohol dependence. Pharmacological drugs are effective in treatment. Relapse prevention techniques and self-help groups are useful. A combination of pharmacotherapy and psychological methods works best for dependent individuals. Improve therapeutic alliance with pharmacotherapy. Enhance compliance with pharmacotherapy through psychosocial interventions.
Annex 1
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Managing non-opioid drug dependence
Co-morbid mental illness
Problematic drug use and:
Schizophrenia Depression Personality disorder Bipolar disorder Anxiety disorder Half of all substance dependents have co-morbid conditions Plus poorer treatment outcomes
Prevalence of one with the other about 45–55%
Assessment Self-report Collateral information Laboratory investigations Screening:
Management issues for co-morbidity
For drug use in those with mental illness
Disability higher from a combination than either alone
For mental illness in drug users Readiness to change
Greatest health impact is from cigarette smoking Co-morbidity usually underserviced
Integration of treatment Parallel / sequential / integrated models of care Fostering engagement and motivation Motivational interviewing / CBT Medication for psychosis, depression and anxiety
Complex social and legal issues Increased risk of suicide, violence, “difficult behaviour” and relapse
Treatment of non-opioid drug use
Summary
A growing problem in Asia No simple pharmacological treatment or psychological therapies Methamphetamine use and dependence the most problematic Some excellent research demonstrates effectiveness of: Peer group support Community reconnection and employment
Be familiar with symptoms of non-opioid dependence and medications used to deal with these symptoms. Be aware of a number of relapse prevention approaches.
strategies Little evidence for residential or other complex
programmes
Co-morbid mental illness requires recognition and treatment Engagement and user-friendly services Assertive outreach
Participant Manual
Treatment and Care for HIV-Positive Injecting Drug Users The “Treatment and Care for HIV-Positive Injecting Drug Users” training curriculum is designed for clinicians who provide treatment and care, including ART, for HIV-positive injecting drug users. The training curriculum consists of a trainer manual, 12 participant manuals, and a CD-ROM with PowerPoint presentations and reference articles. Topics covered in the curriculum include: Module 1: Drug use and HIV in Asia Module 2: Comprehensive services for injecting drug users Module 3: Initial patient assessment Module 4: Managing opioid dependence Module 5: Managing non-opioid drug dependence Module 6: Managing ART in injecting drug users Module 7: Adherence counselling for injecting drug users Module 8: Drug interactions Module 9: Management of coinfections in HIV-positive injecting drug users Module 10: Managing pain in HIV-infected injecting drug users Module 11: Psychiatric illness, psychosocial care and sexual health Module 12: Continuing medical education Trainer manual
The ASEAN Secretariat 70A, Jl. Sisingamangaraja Jakarta 12110 Indonesia Phone: +62 21 724 3372, 726 2991 E-mail: public@aseansec.org
World Health Organization Regional Office for South-East Asia Mahatma Gandhi Marg Indraprastha Estate, New Delhi - 110002 India Phone: +91 11 233 70804 E-mail: hiv@searo.who.int www.searo.who.int
Family Health International Asia/Pacific Regional Office 19th Floor, Tower 3, Sindhorn Building 130-132 Wireless Road, Lumpini, Phatumwan Bangkok 10330, Thailand Phone: +662 263 2300 E-mail: sunee@fhibkk.org www.fhi.org
ISBN 978 979 3496 63 4
978 979 3496 63 4