Substance Use and Harm Reduction Flashcards
Continuum of Substance Use
Beneficial: positive health, spiritual and social impact
i.e. medicinal or spiritual use
Non-problematic: recreational, casual or other use that has negligible health or social effects
Problematic: use at an early age, begins to have negative health impacts
i.e. use by minors, impaired driving, binge consumption
SUD/Addiction: habitual and compulsive despite negative health and social effects
Addiction
- a primary, chronic disease of brain reward, motivation, memory and related circuitry
- dysfunction in these circuits lead to characteristic biological, psychological, social and spiritual manifestations
- pathologically pursuing reward and/or relief
Substance Use Disorder
problematic pattern of a substance use leading to clinically significant impairment or distress, occurring within a 12-month period
- large amounts, long periods
- persistent desire, unable to control use
- ++ time spent
- craving
- failure to fulfil major role obligations
- continued use despite social/interpersonal problems
- tolerance
- withdrawal
- important activities given up or reduced
- physically hazardous
Spectrum of Severity for SUD
Mild = 2-3 symptoms Moderate = 4-5 symptoms Severe = 6+ symptoms
Concurrent Disorder
refers to co-occurring addiction and mental health problems
- may be active at the same time or at different times, in present or in the past
- symptoms may vary in intensity and form over time
i.e. alcohol and depression, cannabis and schizophrenia
Why is it so difficult to stop using?
- activation of areas of the brain responsible for feelings of reward, motivation and reinforcement
- increase dopamine in the brain
- disruption of dopamine levels has effect on decision-making, mood and behaviour
- neural and behavioural impairment
Dependence Liability
substance tends to be more addictive according to dependence liability
- an intense, pleasurable effect, fast onset
- short half-life, need to keep using to maintain pleasure and delay withdrawal
Tx tends to have slow onset and long half life
Intoxication
a state in which the level of consciousness, cognition, perception, judgement, affect or behaviour or other functions and responses are changed after administration of a psychoactive substance
Tolerance
the need for an increased amount of the drug to achieve the desired effect, or reduction of the drug’s effectiveness over time
Withdrawal
an unmasking of the body’s adaptation to the drug’s presence, apparent when the drug is abruptly removed
Dependence
need for the drug in order to feel and function “normally”
physical and/or psychological
Principles of Harm Reduction
accepts that some people may not by ready to choose abstinence and works to minimize its harmful effects
low barrier access to healthcare
accepts that people who are substance-dependent have a voice in the creation or programs and policies that serve them
values patient autonomy
Depressants
slows physiological functions, depresses the CNS
- slows heart rate
- slows breathing
- lowers blood pressure
- decreases body temperature
Manifestations:
- sedation
- disinhibition
- motor incoordination
- slurred speech
- confusion
- disorientation
- impaired judgement
- irritability
Alcohol Use Disorder
medical term for alcohol addiction
can be mild to severe
a. problem-drinking: does not fit criteria for alcohol use disorder, but at risk for accidents and problems
b. moderate: no more than 1 (women) or 2 (men) drinks per day
c. heavy: more than 7 (women) or 14 (men) drinks per week
d. binge: more than 4 (women) or 5 (men) drinks per occasion
CAGE
4-item, non-confrontational questionnaire used to screen and detect AUD
- takes less than a minute to administer
C: do you feel the need to CUT down on your drinking?
A: do you feel ANNOYED by others complaining about your drinking?
G: do you ever feel GUILTY about your drinking
E: do you ever drink an EYE-OPENER in the morning to relieve the shakes?
Score: two “yes” for men, one “yes” for women
Alcohol Use Assessment
- number of drinks
- maximum amount consumed on any day in the past month
- how many bottles and what size per week
- previous week’s drinking pattern
- other drug use
- hospitalization or medication
- risk: driving, childcare, violence, med interaction
Effects of Alcohol
Brain: tremors, peripheral neuropathy, seizures
Cancer: ++ risk, throat, mouth, esophageal, breast
Cardiac: cardiomyopathy, arrhythmias, stroke, elevated BP
Liver: fatty liver, alcoholic hepatitis, cirrhosis, fibrosis
Stomach: bloating, gas, ulcers
Pancreas: pancreatitis
Immune system: weakening, ++ susceptibility to infection/illness
Alcohol Withdrawal
- withdrawal begins 6-24 hours after the last drink
- ranges in severity
- severe alcohol withdrawal can be lethal: seizures, delirium tremens (DTs)
6 standard drinks per day for more than 2 weeks»_space; risk for dependence
Stages of Alcohol Withdrawal
Minor (within 6-12 hours of last drink)
- autonomic hyperactivity
- nausea/vomiting
- coarse tremor
- sweating
- tachycardia
- hypertension
Intermediate (seizures occur between 12-72 hours after stopping)
- autonomic hyperactivity
- seizures
- dysrhythmias
- hallucinations
Major (5-6 days after severe, untreated withdrawal)
delirium tremens:
- severe agitation, confusion, disorientation, hallucinations, psychomotor and autonomic hyperactivity
Clinical Institute Withdrawal Assessment
a. Nausea or vomiting
b. Tremors
c. Anxiety
d. Agitation
e. Paroxysmal sweats
f. Orientation
g. Tactile disturbances
h. Auditory disturbances
i. Visual disturbances
j. Headache
Harm Reduction for Alcohol
- not to stop using alcohol abruptly due to risk of withdrawal seizures
- discuss anti-craving medications
- peer support groups
broad level strategies
- minimum legal drinking age
- impaired driving laws
- smart serve programs
- taxation
- LCBO/hours
Benzodiazepines
one of the most commonly prescribed types of drugs
common indications:
- anxiety disorders (panic, GAD)
- sleep disorders (insomnia)
- alcohol withdrawal
- seizure disorders
Benzodiazepine Withdrawal Schedule
Short-acting Benzos
- within 24 hours of cessation
- peak severity 1-5 days
- can lasts 7-21 days
Long-acting Benzos
- within 5 days of cessation
- peak severity 1-9 days
- can lasts 10-28 days
Symptoms of Benzodiazepine Withdrawal
Vitals: tachycardia, hypertension, fever
CNS: agitation, restlessness, anxiety, disturbances, nightmares, hallucinations, sensory disturbances, irritability
Ears: tinnitus
GI: anorexia, nausea, diarrhea
Severe withdrawal
- seizures
- delirium
- death
WITHDRAWAL MANAGEMENT:
a. slowly tapered
b. in hospital, abrupt d/c managed with phenobarbital substitution
Effects of Opioids
Short-term
- drowsiness
- constipation
- impotence
- nausea and vomiting
- euphoria
- difficulty breathing, worsens sleep apnea
- headaches, dizziness, confusion»_space; falls risk
Long-term
- increased tolerance
- dependence
- liver damage
- menstrual irregularities
- opioid-induced hyperalgesia (worsening pain)
- life-threatening withdrawal in babies whose mother takes opioids
*dependence, overdose, SUD are side effects regardless of why it is being used
Opioid Withdrawal Symptoms
- elevated pulse
- sweating
- restlessness
- dilated pupils
- bone/joint aches
- lacrimation (tears)
- rhinorrhea (runny nose)
- piloerection (goosebumps)
- yawning
- sneezing
- nausea/vomiting
- myalgia, chills
- insomnia, fatigue
- intense craving
onset and duration of withdrawal depends on the half-life of the opioid being used
Management of Opioid Withdrawal
Opioid Maintenance Treatment
administered once daily to prevent/reduce withdrawal symptoms and cravings, prevent relapse, restore physiologic functions
(most successful when used in conjunction with psychosocial intervention)
- methadone
- suboxone (buprenorphine + naloxone)
Withdrawal Management
- clonidine
- methadone and suboxone
Assessment
Clinical Opiate Withdrawal Scale (COWS)
What to do and ask if your patient is on Methadone or Suboxone?
a. find out who is prescribing
b. last date, time and dose taken
c. where client is obtaining medication (pharmacy)
d. using any other opioids/benzos/barbiturates/alcohol
e. clients should receive opioid maintenance meds at the same time each day
f. assess for sedation or intoxication before administering
Harm Reduction for Opioids
a. supervised injection services
- hygienic environment where people can take pre-obtained drugs under supervision
- sterile supplies, education, OD prevention, counselling
- could prevent HIV and HCV transmission
b. naloxone kits
- reverses the effects of opioids
- not addictive, cannot OD, no effect if used in absence of opioids
- IM and IN
c. opioid maintenance treatment
d. needle exchange
Stimulants
- increase activity by stimulating CNS
- reverse effects of fatigue
- speed up mental process, elevate mood
Indicators of Stimulant Use
physical
- increase heart rate, temperature, light sensitivity
- headaches
- changes in taste
- loss of appetite and weight loss
behavioural
- irritability, mood changes
- aggressiveness, hostility
- paranoid
- emotional instability
psychological
- depression, dysphoria
- pseudo hallucinations
- mania
- delusions, psychosis
brain
- damaged nerve cells
- insomnia
- speech problems
- motor or verbal ticks, impaired motor reflexes
Cocaine and Crystal Methamphetamine
may be snorted, smoked, orally ingested, injected or absorbed through mucous membranes
timing and duration depends on route of administration
pattern of use: binge phase and withdrawal phase
Stimulant Withdrawal
can cause profound psychological withdrawal - despair and depression
- depressed mood
- anhedonia
- fatigue
- difficult concentrating
- increased sleep but poor quality
- increase appetite
- GI upset
Tobacco
1 in 5 deaths are related to smoking
life expectancy at least 10 years shorter than non-smokers
increases risk for cancer, pulmonary and cardiovascular disease
Indicators of Hallucinogen Use
behavioural
- hallucinations
- panic with impulsive behaviour
- anxiety
- paranoia and psychosis
- emotional lability
- poor perception of time and distance
- heightened awareness of reality
physiological
- nausea/vomiting
- chills
- tremor
- dilated pupils
- increase BP, respirations and temp
Health Consequences of Hallucinogens
- violence and self-inflicted injuries
- memory loss and speech difficulties
- convulsions, coma
- heart and lung failure
- psychosis
- flashbacks (may occur months to years later)
- impaired judgment and increased chance of accidents
Cannabis
THC - psychoactive component
CBD - little to no psychoactive effect
Therapeutic Uses for Cannabis
Nabiximols (Sativex)
- relief of spasticity in patients with Multiple Sclerosis (MS)
- adjunctive treatment for pain in people with MS or advanced cancer
Nabilone
- severe nausea and vomiting associated with chemotherapy
** There are no approved indications for medical cannabis! Few off label prescriptiong
Effects of Cannabis
Intoxication
- euphoria
- impaired judgement
- motor coordination
Withdrawal
- irritability
- anxiety, depression
- sleep difficulty, vivid dreams
- restlessness
- tremors
Cannabis Use Disorder
- cravings
- recurrent use in physically hazardous situations
- important activities given up or reduced
Short and Long Term Effects of Cannabis Use
Short-term
- impaired short-term memory, difficulty learning and retaining information
- impaired motor coordination, ++ increase of injury
- altered judgement, ++ risk of STIs
- paranoia and psychosis
Long-term
- addiction, cannabis use disorder
- altered brain development in early adolescence use
- poor educational outcome
- cognitive impairment, lower IQ
- diminished life satisfaction
- chronic bronchitis
- ++ risk of psychotic disorder in those with predisposition
Discussing Substance Use
- therapeutic rapport
- ask about substance use routinely, provides opportunities for education and early intervention
- caring and non-judgmental manner
- normalize substance use and acknowledge that it occurs on a spectrum
- offer information, education and support
Stages of Change Model
- Pre-contemplation
- establish rapport, be patient
- acknowledge the role of substance, the good things
- explore meaning
- offer information - Contemplation
- pros and cons list, decisional balance
- identify risks and concerns
- education - Preparation
- explore fears, barriers and harm reduction strategies
- plan quit day
- coping
- discuss medications and counselling - Action
- reinforce success
- plan for slips, normalize
- ongoing review of medications
- quitting is a process - Maintenance
- positive reinforcement, celebrate accomplishments
- talk about ongoing harm reduction and barriers
- prevent relapse - Relapse
- re-evaluate strategies
- reestablish goals
**cycle, but not necessarily linear!
assess client’s readiness and stage of change
“Tell me about your use of substance X”
“How ready are you to change your use? (Scale of 1-10)”
“Would you be willing to change in 1 month? 6 months?”
The Spirit of Motivational Interviewing
- Collaboration
- Evoke or draw out client’s ideas about change
- Emphasizing the autonomy of patient
- Practice compassion
Motivational Interviewing Skills OARSI
Open questions Affirmations Reflect what client is saying Summarizing Informing and advising
Harm Reduction
refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of psychoactive drugs without necessarily reducing drug consumption
emphasis on ENGAGEMENT
- meet client where they are at
- positive change
- small steps
- ending excess suffering and saving lives
- warm turkey
Culturally Specific Framework (Harm Reduction)
- acknowledge and accept the reality of disproportionate adverse effects of substance abuse on specific communities
- intervention must be within culturally specific framework, use what works for the specific community
