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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5536_Библиотеки_им_академика_М_И_Перельмана.pdf
Overview of Drugs
naturally plays an important part in this. Public pressure to share and socialise
around alcohol is very strong, and those who try to moderate or give up may be
criticised. Health care workers can be valuable aids in supporting moderate use
or cessation.
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Prevalence of tobacco smoking is 2 to 3 times higher than the national average, and
there are very high rates of cannabis (yarndi, ganya) use. It has also been recognised
recently that rates of injecting drug use amongst young Indigenous people have
grown exponentially and are associated with very high levels of diseases such as
hepatitis C. There are also increasing levels of use of other drugs such as heroin
with high levels of needle sharing.
General practitioners and other health care workers have considerable potential
to help motivate Indigenous patients to reconsider their drinking and/or drug use.
Health professionals should not feel constrained (e.g. by fears of being culturally
inappropriate), to provide a range of brief interventions to patients just because
they are Indigenous. As is the case with any patient or client, such advice should
be offered sensitively and in a non-judgmental manner, and avoid any implication
of criticism.
Control of drugs
There are numerous governmental offices in many countries that deal with the control
and oversee of drug manufacture and use, and the implementation of various drug
laws. The Single Convention on Narcotic Drugs is an international treaty brought
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about in 1961 to prohibit the use of narcotics save for those used in medical
research and treatment. In 1971 a second treaty the Convention on Psychotropic
Substances had to be introduced to deal with newer recreational psychoactive and
psychedelic drugs.
The Food and Drug Administration (FDA) in the United States is a federal agency
responsible for protecting and promoting public health through the regulation and
supervision of food safety, tobacco products, dietary supplements, prescription and overthe-counter medications, vaccines, biopharmaceuticals, blood transfusions, medical
devices, electromagnetic radiation emitting devices, cosmetics, animal foods and
veterinary drugs.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
GENERAL PRINCIPLES OF MANAGEMENT AND INTERVENTION
The principles involved in identification, management and intervention of alcohol
and other drug (AOD) problems. Problems associated with the use of alcohol or
other drugs can be related to:
■ Intoxication
■ Regular use
■ Dependence
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Overview of Drugs
Not all problems are related to dependence or addiction. Many problems are related
to non-dependent patterns of use that are risky for either the person or those around
them. Interventions should be tailored to the type of problems experienced or the
nature of the risks to which the individual is exposed.
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Harm Minimisation
Harm minimisation is an important principle in the management and intervention
of AOD problems. Many intervention options are pragmatic in nature and based
on an understanding that changing behaviour can be a lengthy, complex process.
From a harm minimisation perspective abstinence may not be the highest or most
immediate priority: Emphasis is placed on reducing as many prob lems as possible
associated with alcohol and drug use, and not just focusing on the drug use per
se. Harm minimisation strategies address the overall health and wellbeing of the
individual and the community at large.
Harm reduction is a range of public health policies designed to reduce the harmful
consequences associated with various human behaviors, both legal and illegal.
Harm reduction policies are used to manage behaviors such as recreational drug
use and sexual activity in numerous settings that range from services through to
geographical regions. Critics of harm reduction typically believe that tolerating risky
or illegal behaviour sends a message to the community that such behaviours are
acceptable and that some of the actions proposed by proponents of harm reduction
do not reduce harm over the long term.
Needle-exchange programmes reduce the likelihood of users of heroin and other
drugs sharing the syringes and using them more than once. Syringe-sharing can
lead to infections such as HIV or hepatitis C, which can spread from user to users
through the reuse of syringes contaminated with infected blood. Needle and syringe
programme (NSP) and Opioid Substitution Therapy (OST) outlets in some settings
offer basic primary health care. Supervised injection sites are legally sanctioned,
medically supervised facilities designed to address public nuisance associated with
drug use and provide a hygienic and stress-free environment for drug consumers.
The facilities provide sterile injection equipment, information about drugs and basic
health care, treatment referrals, and access to medical staff.
Opioid replacement therapy (ORT), or opioid substitution therapy (OST), is the medical
procedure of replacing an illegal opioid, such as heroin, with a longer acting but
less euphoric opioid; methadone or buprenorphine are typically used and the drug
is taken under medical supervision. Another approach is Heroin assisted treatment,
in which medical prescriptions for pharmaceutical heroin (diacetylmorphine) are
provided to heroin-dependent people. Toronto’s Seaton House became the first
homeless shelter in Canada to operate a “wet shelter” on a “managed alcohol”
principle in which clients are served a glass of wine once an hour unless staff
determine that they are too inebriated to continue. Previously, homeless alcoholics
opted to stay on the streets often seeking alcohol from unsafe sources such as
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mouthwash, rubbing alcohol or industrial products which, in turn, resulted in
frequent use of emergency medical facilities.
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A high amount of media coverage exists informing users of the dangers of driving
drunk. Most alcohol users are now aware of these dangers and safe ride techniques
like ‘designated drivers’ and free taxicab programmes are reducing the number of
drunk-driving accidents. Many schools now provide safer sex education to teen
and pre-teen students, who may engage in sexual activity. Since some adolescents
are going to have sex, a harm-reductionist approach supports a sexual education
which emphasizes the use of protective devices like condoms and dental dams to
protect against unwanted pregnancy and the transmission of STIs.
Harm minimisation aims to address alcohol and other drug issues by reducing
the harmful effects of alcohol and other drugs on individuals and society. Harm
minimisation considers the health, social and economic consequences of AOD use
on both the individual and the community as a whole. It has been a key policy
of Australian state and federal governments since the 1985 launch of the National
Campaign against Drug Abuse and the subsequent National Drug Strategy.
Earlier in this module you looked at values and attitudes to AOD use and patterns
of AOD use both by young people and society in general. As with all work on
AOD issues, certain values and beliefs underpin the harm minimisation approach.
The Harm Minimisation Approach
The harm minimisation approach is based on the following:
■ Drug use, both licit and illicit, is an inevitable part of society
Overview of Drugs
■ Drug use occurs across a continuum, ranging from occasional use to
dependent use
■ A range of harms are associated to different types and patterns of AOD use
■ A range of approaches can be used to respond to these harms.
You have already explored a range of models that are used to help understand
drug use. Harm minimisation is based on the public health model. According to
this approach, AOD use is viewed as the result of the interaction between the
following three components: the individual; the social, economic, cultural and
physical environment; and the drug itself. Strategies to reduce harm related to AOD
use are therefore focused on these three interacting components.
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We can also link the harm minimisation approach to the youth-focused systems
approach discussed in Topic 5. The systems approach expands on the public health
model by providing a greater emphasis and depth to the environmental factors
involved. It increases our awareness of the broader societal and cultural factors,
the interactions between different parts of the system and the impact these have on
young people and their behaviours. It helps us to see that interventions to reduce
harm can be directed at different parts of the system.
Goals and strategies for harm minimisation are wide ranging. The approach is broad
enough so that the goals of safer drug use, controlled use and abstinence can all
be accommodated.
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The three components that lead to the drug use experience are:
■ the individual;
■ the environment; and
■ the drug.
Efficacy of Treatment
It is important to stress the efficacy of treatments specific to problematic AOD
use. In contrast to common perceptions, there is a range of effective, empirically
evaluated treatment options available. Treatment can be successful. It is as successful
as many general medical treatments that are held in high regard.
Intervention earlier rather than later is strongly recommended. Treatment for longterm chronic problems can also be very effective.
Overview of Drugs
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Early Recognition And Screening
Early recognition is important as it can enable intervention to occur before dependence
or irreversible damage has developed. However, alcohol and drug problems can
be difficult to detect, especially in the early stages.
Reasons include:
■ Not knowing what to look for
■ Lack of vigilance
■ Embarrassment about asking questions
■ Not knowing what to do if a problem is uncovered
■ The person’s denial or evasion
Detection rates can be improved by:
■ routine enquiry about alcohol and drug use
■ screening questionnaires
■ biological screening (pathology tests)
■ knowledge of common clinical presentations
Routine Enquiry About Alcohol And Drug Use
General practice and primary health care offer a variety of opportunities to enquire
about alcohol and drug use; for example, in the context of:
■ new patients as part of initial information gathering
■ management of chronic problems alcohol for example, is a risk factor in
cardiovasculardisease, diabetes, depression
■ management of acute problems, especiallytrauma, gastrointestinal disorders,
anxiety/stress, psychological problems
■ preoperative assessment
■ pre-conception and antenatal care
■ enhanced Primary Care Medicare Benefit Schedule items health assessment,
care plans and case conferences
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Screening Questionnaires
Use of general questionnaires covering lifestyle issues such as smoking, diet, exercise,
alcohol and drug use may be less threaten ing and stigmatising for patients.
There is also a number of short, well validated questionnaires which can be used
to screen for alcohol problems. Screening and brief interventions can readily be
combined in a single general practice consultation.
Biological Screening
A number of blood tests can be used to screen for alcohol problems. However, they
can be less sensitive and specific than questionnaires. These screening tests include:
■ Full blood count, including MCV
■ Liver function tests, including gamma GT
■ Triglycerides
Urine testing can detect alcohol, other drugs (e.g. cocaine, opioids cannabis,
benzodiazepines and barbiturates) and/or their metabolites.
Screening tests for drug use include:
■ full blood count, including white cell count
■ liver function tests
■ hepatitis B and C and HIV serology
Overview of Drugs
47
Common Clinical Presentations
Indicators of alcohol- or drug-related problems are wide-ranging and can involve:
■ Cardiovascular
■ Gastrointestinal
■ Musculoskeletal
■ Neurological
■ dermatological
■ genito-urinary systems
■ accidents/trauma, social and legal incidents
Indicators of problematic drug use can include:
■ infections (injecting users)
■ accidents/trauma
■ psychiatric problems
■ behavioural, social and legal incidents
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Assessment
Assessment is critical and has several purposes:
■ to identify substance use behaviour early
■ to discover the extent of use and its health effects
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Illustrated Handbook of Drugs & Alcohol Related Health Issues
■ to examine the social context of substance use in both the patient and
significant others
■ to determine a care plan and appropriate interventions
The assessment phase should fulfil four important functions:
■ Developing a therapeutic relationship based on trust, empathy and a non-
judgmental attitude
■ Helping the client to accurately reappraise their drug use, which may in
turn facilitate the desire to change
■ Facilitating a review of the client’s past and present circumstances and
linking these to current drug use
■ Encouraging the client to reflect on the choices and consequences of drug
using behaviour
Traditionally treatment success was measured by abstinence. Today there is more
emphasis on the client’s:
■ wellbeing
■ beliefs about drinking and drug use
■ readiness to change
■ alcohol- and drug-related expectancies
■ social functioning and social support
These are all important predictors of success. Current approaches to treatment of
alcoholand drug-related problems reflect a continuum of treatment.
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