Polydrug Use

Polydrug Use

Polydrug Use

Polydrug Use Defined

Polydrug use refers to:

“...the concurrent use of multiple drugs, or the combining of drugs. It can occur in a range of patterns and for a variety of reasons, and may or may not involve drug dependence.”

Swan & Ritter (2001, p. 1)

Polydrug Use

Polydrug Use• Becomes a concern in terms of its relative risk

• Generally associated with hazardous or harmful use of > 1 drug

• Appears to be ‘the norm’ amongst many drug-using groups

– many of whom rarely limit use to one drug, or

– who use a primary drug along with a range of other drugs

• Is highly prevalent among clients of drug treatment services.

Polydrug Use

Patterns of Polydrug Use

Think about: context, patterns of use and dependence

Common patterns of use include:

– using from multiple drug classes, but there is no evidence of dependence on any one class of drug

– dependence on one drug class, but use of other drugs

– dependence on several drugs or classes of drugs.

Polydrug Use

The Nature of Polydrug Use

Polydrug use depends on a range of factors:

– demographic and social

– availability and price

– desired effect and outcome of use

– previous experiences (institutionalisation or previous medical treatment appears to influence polydrug use behaviours).

Polydrug Use

Reasons for Polydrug Use

• To enhance effects of other drugs

• To counteract effects of other drugs

• To provide a substitute for a preferred but unavailable drug

• To conform to normative ways of using drugs

• To counteract the unpleasant effects of drugs from different classes

• To self-manage the withdrawal from one drug by using another.

Polydrug Use

Common Drug Interactions (1)

Drug combo Degree ofinteraction

Effects

BZDs + alcohol +++ sedation, intoxication, risk of OD

BZDs + opioids +++ sedation, intoxication, impairment,risk of ODcommon in MMT and elderly

Cannabis +stimulants

+++ offsets cannabis sedation, pulsegreater than either drug alone

Cannabis + alcohol ++ intoxication and impairment

Polydrug Use

Common Drug Interactions (2)

Drug combo Degree ofinteraction

Effects

Opioids +prescribed drugs

- to +++ various meds interact, precautionsneeded for those which respiratorydepression or sedation

Opioids +antihistamines

+++ intoxication, sedation andimpairment

Opioids +stimulants

++ intoxication sedation

Polydrug Use

Harms from Polydrug UseIntoxication, Regular Excessive Use and Dependence

Intoxicationaccidents

overdose and poisoninghangovers

absenteeismhigh-risk behaviour

Regular Excessive Usehealth

financesrelationships

work

Dependenceimpaired control, drug centred behaviour

severe social or psychological problems, withdrawal

I R

D

Polydrug Use

Service Provision and Polydrug Use

• Engage into treatment

• Ensure effective collaboration

• Use Harm Reduction strategies

– prevention BBV, reduce use, crisis intervention

• Multimodal treatment and cross referral

• Regular review.

Polydrug Use

Polydrug Assessment Issues (1)

• Conduct a systematic assessment of each drug class

– episodic use, time frame of at least 4 weeks, changing patterns of use with changing availability, dependence (>1 drug?). Include tobacco !

• Examine relationship between use of various drugs

– Is use of one drug related to the absence or use of another? Any drug free periods? Use of one drug to modify withdrawal from another?

• Identify drug use patterns, dependence and high-risk using practices

– use of drugs from different classes +/- dependence on one or all.

Polydrug Use

Polydrug Assessment Issues (2)

Try to gain a sense of:

• patient’s reasons for choosing to use particular drugs

• their multiple problems or concerns

• how their drug use and lifestyle affects them (include both positive and negative aspects)

• potential for withdrawal.

Polydrug Use

Screening• WHO is developing a composite polydrug

screening instrument:

ASSIST: Alcohol, Smoking & Substance Involvement Screening Tool

• To be used in primary health care settings to help GPs decide whether the patient will benefit most from:

– information

– brief intervention, or

– referral to specialised treatment.

Polydrug Use

Other Assessment Issues• Allow adequate time (more time is needed

than for a single drug assessment)

• Obtain corroborating information

– e.g., friends / family, with consent

• Delay assessment if intoxicated – apply harm reduction principles

• Consider your role and the practice staff in the management of people with complex polydrug use issues.

Polydrug Use

Key Issues in Treatment

• Harm mimimisation strategies a priority

• Opportunistic brief interventions are often all that can be delivered

• Long-term treatment perspective is required – few people abandon all drug use in the short term

• Numbers of drugs used tend to with age

• Patients may only be interested in dealing with most immediate/problematic issues.

Polydrug Use

GPs and Management (1)

• Polydrug issues are complex, patients often present in crisis. Clarify your role

• Consider a ‘shared care’ approach:

– AOD specialists (including mental health services)

– relevant local health and welfare agencies

– crisis intervention services

– families and other peer support groups (esp. useful with young people).

Polydrug Use

GPs and Management (2)

• Develop ongoing therapeutic relationship (BI, counselling etc.); encourage return despite possible frequent non-attendance

• With patient, identify which (most harmful) drug to tackle first for stabilisation or withdrawal

• Polydrug withdrawal is complex – work with (or refer to) specialists

• Ensure contact and liaison with other AOD services.

Polydrug Use

Who is Suitable for Counselling?

• Counselling is suitable for those who:

– self-identify as polydrug users

– are subject to court orders

– are pressured into treatment by employers, family or friends

• Counselling is not suitable for those who:

– are actively psychotic

– have significant cognitive impairment or intellectual impairment

– are grossly intoxicated.

Polydrug Use

A Final Comment

If the young polydrug user can be kept alive, and free of disease, there is a natural tendency towards eventually moderating or giving up drug use.

Treatment may provide ‘a nudge along the natural pathway of recovery’.