Download Does the Client use alcohol?

Fuel to the Fire?
Drug Users Who Drink
Is there a problem?
1990 – Almost 100% was Alcohol problems
In 1992 3% of our Clients were under 25
No IVDU
Prescribed use Minimal
2002 an equal split between age groups
High amounts of Heroin use
Rapid transition to IVDU
2002 we started to notice a link between drug and alcohol use
Arising Awareness
At first through observation on street
work and needle exchange
By requests for Alcometer
Through alliances between at first
apparently disparate groupings
Through networking
Locations
Other Issues
Interaction with other drugs – Lothian
Overdoses
Issues around HEP C
Aggression and Violence
But Why?
Lets Revisit
God’s Own Medicine
Sir William Ostler
"I'll Die Young, but It's Like
Kissing God"
The Consumption of Heroin Is Marked by
a Euphoric Rush, a Warm Feeling of
Relaxation, a Sense of Protection, and a
dissipation of pain, fear, hunger, tension
and anxiety.
When Heroin Is Snorted or Smoked but
Especially Injected, the Rush Is Intense
and Orgasmic. Subjectively, Time May
Slow Down. Anger, Frustration and
Aggression Magically Disappear.
We replace with
Methadone
DF118s
Enforced Reduction
Abstinence Alone
Remember …
Heroin Works..
Quickly
Consistently
Without work
Efficiently
Works well with trauma
Client C
I hated drugs – hated drug users but
one night I was rattling of the drink
someone gave me a burn – I felt
normal for the first time in my life
Other Possible Factors In Rise Of
Alcohol use
Controlled Dispensing
Diazepam ceilings
Fake Diazepam
Mundanity of methadone Lifestyle
Social Exclusion
The Muirhouse Experience
Reasons for research
Initiated through NEAR
Response to new problem
Identified as not conventional issues
Of the twenty-five interviewed, 17 (68%)
were living in Muirhouse, while six (24%)
were from the immediate surrounding
areas (e.g. West Pilton), and two (8%)
were from other parts of Edinburgh
although originally from the Muirhouse
area. Only one (4%) of the group did not
stay in their own home, while 96% of the
group rented their own council flats.
Twenty-one (84%) were registered with a
GP in the area. It is important to
recognise that all the Street Drinkers
interviewed had long connections with the
area, and that all had stayed in the area
at one time or another for significant
periods
Frequency of drinking
Once every two
weeks or less
13%
4%
8%
Once a week or
less
Once/twice a week
54%
21%
More than twice a
week
Every day
Consumption
The average daily units consumed by
those that drink at the Muirhouse
Shopping Centre were 9.6, although
this was only based on data from ten
people. The majority of the street
drinkers were unable to estimate
how much they drank on a typical
day, and reported that it was
dependent on other variables such as
availability and mood.
Attitude to Drinking
When asked how they felt about their
drinking patterns, 58% of the group
replied that they were unhappy with
the level of alcohol intake. Of that
58%, half wished to drink less, and
the remaining half wished to stop
drinking altogether
But All very Interesting…
Drugs
The vast majority of those
interviewed were on maintenance
prescriptions
Practically all had at one time used
opiates in one form or another
Routes for help
Proposed avenues of assistance
50
45
40
35
30
25
20
15
10
5
0
Friends
Family
GP
NEDAC
Police
Social Work Community Groups
Housing
Support Worker
Why Lack of Clarity?
Social acceptability of alcohol
Inability to assess
Unwillingness to challenge
Scale of issue compared to Heroin
Alcohol Dependency Syndrome







1. Narrowing of drinking repertoire
2. Salience of drink seeking activity
3. Increased tolerance
4. Repeated withdrawal symptoms
5. Relief drinking
6. Awareness of compulsion to drink
7. Rapid reinstatement after
abstinence
For us as drug workers…
Alcohol misuse by clients undergoing
Methadone Treatment Programmes
has been recognised as a factor in ….
• Poor treatment outcome
• Increased morbidity
• Early termination of treatment


Methadone/Opiate related death
Increased social, family and
psychiatric disorder
Client J
I found myself at the offy at 7.30 in
the morning ..I would look at the
troops at the pharmacy waiting for
their script and say” Thank god I’m
nae like them no more” ..”I didn’t
know it I was worse”
Size of the Problem
Heavy drinking is widespread among
drug users. Heavy drinking can be a
serious threat to the health of drug
users because of the high rates of
liver disease among drug injectors
and because of the increased
potential for drug overdose when
alcohol and drugs are used together
Size Of The Problem
20.9% of Methadone Maintenance
clients have been shown to meet the
criteria for alcohol dependence
Alcohol Consumption – NTORS
National Treatment Outcome
Research Study





68% reported drinking alcohol in the 3
months prior to treatment
32% had not consumed any alcohol during
this period
27% of clients drank above recommended
limits
14% of the clients drank on a daily basis
8% were drinking in the region of 45 units
on a daily basis
Alcohol Consumption - NTORS
Among the drinkers, the average
alcohol consumption by men was 50
units per week (compared to 15.4
units in general population) and
among women 45 units per week
(compared to 5.4 units general
population)
Alcohol Consumption - NTORS
Heavy drinking can present serious
problems for a proportion of the
treatment population and it has been
suggested that treatment programs
for drug users sometimes overlook or
fail to respond effectively to alcohol
problems
Alcohol and other drugs




Amphetamines
Cocaine
Benzodiazepines
Club scene drugs
• Particular risks with GHB & Ketamine

Solvents
Physical effects of drinking








Raised LFT’s - Fatty liver - Cirrhosis
Gastritis
Pancreatitis
Ca- Mouth, larynx, Oesophagus
Hypertension
Diabetes
Intoxication
Falls, accidents
Physical





Sexual dysfunction
Flushed face
Aggression
Interaction with other drugs
Withdrawal’s
• Tremors, Sweats etc.
Psychological effects







Depression
Anxiety
Insomnia
Suicide/attempted suicide
Amnesias
Hallucinations
Dementia





Phobias
Obsessive compulsive disorders
Aggression
Changes in personality
Guilt
Social







Relationship problems
Divorce
Work difficulties
Financial difficulties
Child care issues
Housing difficulties
Legal problems
• Drink driving
• Burglary
• Shoplifting
• Crimes of violence
Asking about Alcohol





Should we do it, is it our job?
Do we have the skills?
Do we have the support?
Routine, as part of initial contact
Opportunistically - In response to
further information
Asking about alcohol


Routine - Everyone is
asked about their
drinking (screening
tools?) and
information is
recorded in relation to
quantity, frequency,
motive and
consequences
Feedback and
interventions are
based on the above

Opportunistic -
Certain
issues should make you
clarify drinking
• Smell or intoxication
• Evidence of cans or
bottles
• Symptoms of
withdrawal- shaking,
sweating
• Reports by - family,
professionals, self
• Alcohol related offences
• Stress, anxiety, low
mood, sleep
disturbance
Asking people how much they drink

the information which patients provide is
sufficiently truthful to give an accurate
indication of their risk from alcohol”


Royal College of GP’s (1986)
For most purposes and for most patients,
self reported alcohol consumption will
provide a useful and satisfactory indicator
of drinking behaviour.
Assessing Alcohol Use


Every client should be asked about their
drinking and specific information about
this should be recorded in their notes/care
plan
Observable signs and symptoms
• Intoxication
• Smell (Alcometer)
• Symptoms of withdrawal

Tremors, sweats
• Physical stigmata

Puffy/flushed face, Weight changes
Assess current consumption:• What
• How much - ABV & Quantity
• How often
• How long for
• Why
• Where, Who with
• DIARY
Alcohol Strengths






Draught beers/lagers/ciders 3-6%
‘Special Brews’
9%
Table wines
8-14%
Sherry, Port etc
15-22%
Spirits
35-40%
Liqueurs
2055%
Abrupt Cessation
Alcohol Withdrawal Continuum
Drugs used in the treatment of
alcohol problems

Drugs used in withdrawal
• Chlordiazepoxide (Librium)
• Chlormethiazole (Hemineverin)
• Diazepam

Drugs used in relapse prevention
• Disulfiram (Antabuse)
• Acamprosate (Campral)
• Naltrexone

Vitamin replacement
• Thiamine
• Vitamin B complex
• Pabrinex
Naltrexone
I hear you say?
When used as an adjunct to psychosocial
therapies for alcohol-dependent or
alcohol-abusing patients, naltrexone can
reduce
 The percentage of days spent drinking
 The amount of alcohol consumed on a
drinking occasion
 Relapse to excessive and destructive
drinking
Naltrexone therapy improves treatment
outcomes when added to other
components of alcoholism treatment. For
patients who are motivated to take the
medication, naltrexone is an important
and valuable tool. In many patients, a
short regimen of naltrexone will provide a
critical period of sobriety, during which the
patient learns to stay sober without it.
How does Campral work?
Acamprosate (Campral) reduces the
craving for alcohol by inhibiting a
chemical in the brain called gamma
aminobutyric acid (GABA). Several
studies have indicated that it may
help drinkers remain abstinent
Does the Client use alcohol?
If Yes:- How Much, How Often, etc
Is the clients alcohol use a factor
in their presentation?
If No:- Record,
Keep under
review
If Yes - Give feedback/Info
Does the individual want to make changes
in their alcohol use?
If Yes:- Offer options -Set
Goals -Action Plan - Monitor
Active Treatment/
Relapse Prevention
If No - Plan management
accordingly
Engage/Persuade/Set

What practical steps could you take
to address alcohol use amongst your
drug using clients
• On an individual basis
• On an organisational basis
What may be the barriers to addressing alcohol amongst your clients
Practice Issues to consider






Harm Minimisation
Hepatitis C/B
Increased risk associated if also
using Benzodiazepines
Individuals substituting alcohol for
opiates while stabilising on
methadone
Staff Training
Risk assessment - Overdose etc
Other Issues




Baseline assessment
Inclusion in careplanning
Inclusion in outcome monitoring
Policy for managing alcohol
• Ongoing assessment (Use of alcometer)
• Managing alcohol use

Working with alcohol services
• Boundaries for acceptable behaviour
(No alcohol allowed in clinic etc)
Do you Need To?
Change prescribing practice?
• Daily pickup
• Supervised consumption
• Withholding scripts (Alcometer)
• Do they above make a difference?
Skills







Assessment - Screening tools, drink diary,
pro’s and con’s, exchanging info.
Readiness to change taken into account Importance and confidence, Motivation
Dependency issues
Goal setting
Problem solving
Dealing with relapse
Coping with cravings
NTORS
All drug services need to look at
strategies to keep alcohol on their
agenda
There is no longer a Berlin Wall