THE PERSON WITH SUBSTANCE USE ISSUES (ADDICTION)
Addiction driven by:
• Genetic driven component
• 28% of Australians perceived acceptable for misuse of pharmaceuticals
• Cyclical usage drives inhibition of control (VTA ®dopamine ® nucleus accumbens (Pavlovian conditioning) ® craving + withdrawals ® harder to
break cycle)
• Treat “addiction” as a chronic disease and a proper diagnosis– cannot be addressed with short-term Mx
• Appreciate that recovery is progressive è Understand – what do we learn from relapse? What were the causes?
• Mandatory reporting ONLY for RoSH others or themselves è local MH care call line
Drug and alcohol history: Main classes of drugs:
Ø What is the primary substance of concern (e.g EtOH, drugs)
o Frequency, dosage (quantify), route of administration (oral, intranasal, injectable) 1) Stimulants (MDMA, ecstasy, cocaine,
o Duration of usage + REASON (when started and with who?)
nicotine)
o Assoc. activities (e.g. social setting, work)
o Acquisition of substance 2) Depressants (opioids, EtOH, nicotine,
o Escalation of behaviour (SUICIDAL ATTEMPTS, CRIME) cannabis)
o Previous withdrawals (e.g. seizure, psychosis) or previous hospital Axs 3) Hallucinogens (LSD, psilocybin)
Ø Past Hx of injecting drugs and behaviour:
o Injection location (e.g. IJV – stroke)
4) Sedatives (benzos)
o Sharing needles (access of needles – are they aware of needle replacement) 5) Inhalants (e.g. Nitrous)
o Filters use (to remove contaminants) 6) Others (pregabalin, quetiapine)
o HCV/HIV
o Concomitant use of benzo and alcohol
o Previous ODs
Ø Other addictions – identifying root cause: (IMPACTS ON ADL)
DSMV criteria for drug disorder:
o Gambling, gaming, shopping 1) Impaired control ® cravings
o Risks of addiction (e.g. syncope, falls, LOC, seizures, driving, violence)
2) Social impairment ® absenteeism,
o Why has patient developed addiction –underlying cause? – social context, personal stresses,
boredom, rebellion damaged relationships, reduced ADL
o What are these barriers and obstacles that need to be overcome, ATTEMPTS TO QUIT (e.g. surfing)
Ø PMHx:
o Nutrition
3) Risky use ® IVDU, unprotected sex,
o Psych history è diagnoses, # of MH admissions, suicide/self-harm attempts, mood , LoA tattoos, polydrug usage
o MH è personality disorder, schizophrenia 4) Pharmacological Properties ®
o Developmental history è adverse childhood trauma
Ø FHx:
tolerance (needing more to get same
o Family member usage of substance effect), withdrawal (e.g. sweat &
Ø SHx: tremor for EtOH, cold-flu like Sx for
o Employment /education (poor academics – ADHD?, autism?)
opioids)
o Current Home life + family (?isolated, live alone, other loved ones using drugs?)
o Forensic and law (?AVOs against/from them, DUY, family court pending) Severity of addiction:
PHYSICAL EXAM: INTOXICATION OR WITHDRAWAL PHYSICAL EXAM: Medical issues Ø Mild = 2-3 symptoms
Ø Confusion (e.g. Wernicke’s, DT’s) • MSE – sensory, intoxicated, mood Ø Moderate = 4-5 symptoms
Ø Psychosis (e.g. stimulant related) • Vitals Ø Severe = >5 symptoms
Ø Drowsy (alcohol, benzos, opiates) • Track marks (recent/old) - IVDU ® check
Ø Agitated (sedative withdrawal, or stimulant site, cellulitis
toxicity) •
Ø Tremor (alcohol, BZD withdrawal) • LN
Ø Diaphoresis (alcohol and opioid withdrawal) • Liver
Ø Slurred speech (alcohol, BZD intoxication) • Heart
Ø Pupils (esp. opiates)
• Lung
• CNS/PNS - CVS ® cocaine
MOTIVATIONAL INTERVIEWING:
Ø A form of patient-centred care, a particular way of having a conversation about change in which you
seek to strengthen the patient’s own motivation for and commitment to do what is needed.
Ø AVOID righting reflex and using the term “denial”
Ø Positives of motivational interviewing (esp. for alcohol, nicotine and cannabis users)
o 10-15min Patient centred approach effective for non-dependent substance use
o Reduction sustained for 6-12 months
o Independent of gender or intervention intensity
o FU associated with better outcomes
Other management options:
Ø Negatives 5) Relapse prevention
o No real difference between MET and other active treatments a. Teach behavioral strategies to
Steps Process dela with this e
1) ENGAGEMENT • Empathic listening and building rapport (
b. escape plans”, drink refusal,
Recognise • OARS = e.g. opened questions, affirmation, reflection and summarizing problem solving
Express concern Aim = elicit change talk (DARN = desire, ability, reason and need for change) c. identifying high risk situations
Intention to change • D – “I would really like to…” such as cravings, social pressure,
Optimism about change • A – “I was able to stop for…” interpersonal conflicts
• R = “I have to stop smoking to avoid asthma attacks, see my child grow up) 6) Self-help groups (AA and 12step
• N – “I need to stop this…” programme)
2) FOCUSSING Patient-led – i.e. what changes in behaviour do they want to focus on 7) SMARTRecovery - Group-based CBT
3) EVOCATION Develop further change – e.g. positive or negatives about change, discuss reasons based with goal of abstinence (fewer
for change meetings)
4) PLANNING Patient makes the plan – i.e. what do you want to try or tried in the past and how
might you achieve this?
, Smoking + Alcohol Cessation
Smoking Addiction Alcohol use disorder (AUD)
When Life event, stresses, traumatic past event, FHx of substance abuse
did it all Beware BZD and barbiturates withdrawal presents similarly
Ask start and to alcohol withdrawal since ALL act on GABA receptors
why?
• Smoking pack years, • (AUDIT-C) è How often drinking alcohol | Number of standard drinks/day |
Quantify
• 3 W’s? When and where do they smoke or drink and with who? binge drinking
usage
• 3 W’s? When and where do they smoke or drink and with who?
Risk • High risk groups = pregnant, ATSI, adolescents, pregnant, elderly
factors • Social circumstances = mental illness, DM, CVD, low SES
• Previous attempts to quit
• Barriers to relapsing (family member or partner usage, peer pressure) CAGE Questions (“yes” to any 2 = need further Ix
• how many minutes to 1st cigarette after waking (smoking within
Control Ø Cut down attempts
30 minutes = nicotine dependence)
Ø Annoyed about drinking habits
• Withdrawal symptoms = tremor, tachycardia, sweating
Ø Guilty about drinking
• Cravings/Dependence symptoms = anxiety, aggressive, agitated
Ø Eye-opener (within 30mins = bad)
Impact • Relationships and social life (Lives alone or with someone) ® homeless, domestic violence
on life • Occupation - job jumping, loss of jobs
Assess (ADLs) + • Assoc. injuries/Drink and driving? / truck/train driver
SHx o Crimes, law infringements, incaceration
• Mental health issues (A+D, schizophrenia, bipolar) – very big barrier – more likely to relapse and withdraw
Psych • Impact on sleep, mood, concentration, appetite
• Intrusive thoughts – thoughts of self harm and suicidal ideation
• Previous hospital admissions • Previous hospital admissions
• Concurrent smoking + illicit drug usage • Concurrent smoking + illicit drug usage
PMHx
• Pre-existing lung disease (COPD, asthma, ILD) • EtOH-related illness (pancreatitis, PUD, liver disease)
• CVD or RF = CAD, HC, DM, HTN, AF • Regular meds (alcohol mixing esp. benzos, opiates)
• Pre-contemplation: no interest in changing behaviour
1. ASK – identify issue
Are they • Contemplation: an awareness of the negative aspects of smoking 2. Assess – barriers, dependence
ready to • Preparation: an understanding of why they should quit smoking 3. Advise – willingness to quit?, best things you can do for your health is quit
quit? • Action maintenance: an attempt to stop smoking 4. Assist -quit date, support?
5. Arrange – f/u- celebrate success + review failures for relapses
• Relapse: the attempt to quit was unsuccessful
• “The best thing you can do for your own health is to stop smoking” • Emphasise benefits of reducing EtOH ® save money, reduce cancers, better
• Save money memory, reduce stress and liver damage
Benefits • Understand that withdrawal symptoms is NORMAL and that taking
• Biggest cause of preventable illness such as stroke, MI, PE, throat,
Advise to quit
mouth, lung cancer, OP, impotence alcohol/smoking is not ideal
(educate)
• Doing it for baby on the way • Strong association w/ suicidal risk (2x in ATSI)
• Reassurance that I will support them • Stop for pregnancy
1. Set quit date based on level of motivation 1. Set quit date based on level of motivation
STAR 2. Tell friends and family to support efforts 2. limit alcohol ≤ 2 standard drinks
3. Anticipate challenges/relapses – peak withdrawal on day STAR
(goals) 3
3. Tell friends and family to support efforts
(goals)
4. Recommend counselling programs + consider meds 4. Anticipate challenges/relapses (socialising + withdrawal)
Ø Face-face CBT counselling (trained therapist) 5. Recommend counselling programs + consider meds
Non-
Ø Group counselling (community setting) Ø ↑Lifestyle = Encourage hydration + PPI (if sig. N/V)
pharm
Ø Quitline 13 78 48 Ø = improve sleep hygiene+ decrease stresses
Ø Nicotine replacement therapy (1st line) = patches, sprays
Non- Ø Home detox program (only if sufficient carer support)
(avoid in AF, HTN, ACS)
DUAL therapy – oatchy – switch size, gum (craving)
pharm Ø Community programs (if unsuitable for home)
STEP 1 (21mg)® STEP 2 (14mg) ® STEP 3 (7mg) Ø drug and alcohol support – NSW healthcare pathway if
Ø Bupropion è NORAD, Dopamine reuptake inhibitor and continued relapses
nicotine antagonist
Pharm (start 1-2 wks before quit date then for 12 weeks)® may
Ø Anti-craving agents ® naltrexone, acamprosate
cause hypersensitivity reactions, seizures, eating o AVOID for withdrawal -® use BZDs
What disorders Ø PO diazepam in early phases of withdrawal to prevent
can we Ø Varenicline (Champix) (start 1-2 wks before quit date seizures (RAPID ONSET AND LONG HALD LIFE)
Assist do get then for 12 weeks – nicotinic partial agonist (most Pharm
effective)® may cause hypersensitivity reactions Ø Prophylactic = PO 100mg thiamine od for 1 to 2 wks
started?
Ø E-cigarettes = no evidence (last line) Ø Alcohol sensitiser (Ca carbamide or Disulfiram ) =
unpleasant reaction when taking EtOH (vomit, flush,
nausea)
Specific pt Specific Treatment Suppressed SNS causes overactive SNS during withdrawal:
• 1st & ONLY line = nicotine replacement [withdrawal Sx peaks 48-72 hrs after last drink]
BF women /
• Encourage to stop smoking (emphasise Ø 6-24 hrs = anxiety-like symptoms, restless, inattentive,
pregnant
effects on foetus) insomnia
• ↓ antidepressant before starting buproprion Ø 24 hrs = hallucinations, hypervigilance, vivid dreams
Depression Delirium
• 2nd line = Notriptyline Ø >48 hrs = Grand-mal seizures, tremors, ANS hyperactivity
Tremens
• 1stline= nicotine replacement Rx: (F/U on blood and advise on side-effects)
Schizophrenia Ø Move to quiet safe environment to prevent harm
• CI = Buproprion (cause psychosis)
Ø Timely IV thiamine or pabrinex (B1, B2, B6) =1st line
Ø 2nd line = benzo (diazepam with weaning dose)
• Ø IVF – Rehydrate ® ECG, lipase
1. 1-2 weeks to see progress then every month 1. Regular FU + monitor LFTs every 4 weeks
2. At 3/12 and 1 year - check on side effects, smoking status and relapse 2. 1-2 weeks to see progress then every month
3. NB: highest relapse rates within first 3 mths of cessation Routine bloods – FBC, EUC, LFT (++ggt, albumin) + screen for
• GI (Cirrhosis) = ascites, jaundice, HM, spider naevi, gynecomastia
Arrange FU
Side effects: • Neuro = nystagmus, ataxis, peripheral neuropathy, ophthalmoplegia
Ø Bupropion = insomnia, seizure • CV = cardiomegaly, peripheral oedema’
Ø Vernacaline = nausea (will subside) + nightmares • Intoxication signs = Physical injuries (bruises), slow motor response, altered
mental state, delirium tremens!!
