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Volume C: Addiction Medications and Special Populations Volume C: Addiction Medications and Special Populations Treatnet Training Volume C: Module 1 –

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Presentation on theme: "Volume C: Addiction Medications and Special Populations Volume C: Addiction Medications and Special Populations Treatnet Training Volume C: Module 1 –"— Presentation transcript:

1 Volume C: Addiction Medications and Special Populations Volume C: Addiction Medications and Special Populations Treatnet Training Volume C: Module 1 – Updated 19 February 2008

2 Volume C: Addiction Medications and Special Populations Module 1: Addiction Basics: Alcohol and Benzodiazepines; Psychostimulants, Volatile Substances, and Cannabis Workshop 1 Workshop 2 Workshop 3 Module 2: Opioids: Basics of Addiction; Opiate Agonist, Partial Agonist, and Antagonist Therapies Workshop 1Workshop 2Workshop 3 Module 3: Special Populations: Individuals with Co-Occurring Disorders, Women, and Young People Workshop 1Workshop 2Workshop 3 Workshop 4

3 Module 1: Addiction Basics: Alcohol and Benzodiazepines; Psychostimulants; Volatile Substances and Cannabis

4 Module 1: Training goals 1.Increase knowledge of the medical and addiction-related problems associated with alcohol, benzodiazepines, psychostimulants, volatile substances and cannabis. 2.Learn the appropriate medical detoxification and post detoxification pharmacotherapies appropriate to treat these substance use disorders. 3.Promote the use of these techniques by practionners and organizations

5 Module 1: Workshops Workshop 1: Addiction Basics Workshop 2: Alcohol & Benzodiazepines; Medical Issues, Detoxification Approaches Workshop 3: Psychostimulants, Volatile Substances and Cannabis

6 Icebreaker: Drugs in my country What is the main consumed drug in your country? What is the main consumed drug in your country? What are the main problems that this drug is creating among people in your country? What are the main problems that this drug is creating among people in your country? 15 Min.

7 Workshop 1: Drug Abuse and Addiction Source: NIDA (www.projectcork.org)

8 Pre-assessment Please respond to the pre-assessment questions in your workbook. (Your responses are strictly confidential.) (Your responses are strictly confidential.) 10 Min.

9 Training Objectives At the end of this training you will be able to: 1.Understand basic principles and concepts of drug abuse and dependence. 2.Understand the basic pharmacology of alcohol, benzodiazepines, psychostimulants, volatile substances and cannabis 3.Understand the specific role of pharmacotherapy for overdose, withdrawal treatments, maintenance treatments and relapse prevention treatments. 4.Understand clinical populations and treatment settings where pharmacotherapies can be used.

10 Why do people initiate drug use? Key Motivators Fun (pleasure) Fun (pleasure) Forget (pain amelioration) Forget (pain amelioration) Functional (purposeful) Functional (purposeful) (NCETA, 2004) (NCETA, 2004) Also initiation starts through: Experimental use Experimental use Peer pressure Peer pressure

11 1.Risk-takers / pleasure seekers 2.Socially disconnected 3.Self-medicators Understanding young peoples motivation to use drugs

12 Types of drug users Enormous variability and range include: Experimenters Experimenters Social users Social users Regular heavy users Regular heavy users Dependent users Dependent users

13 dependent intensive purposive experimental Patterns of drug use

14 Factors that influence drug use There are at least three different categories of factors to consider: predisposing factors predisposing factors precipitating (enabling) factors precipitating (enabling) factors perpetuating (reinforcing) or maintaining factors perpetuating (reinforcing) or maintaining factors

15 Drugs and genes While psychological theories account for a large proportion of the behaviours related to drug use, other factors are also important While psychological theories account for a large proportion of the behaviours related to drug use, other factors are also important It is increasingly recognised that genes play an important role in an individuals response to drugs and the propensity for the development of dependence It is increasingly recognised that genes play an important role in an individuals response to drugs and the propensity for the development of dependence

16 Environmental factors A range of environmental factors impact on drug use, including price and availability of both licit and illicit drugs A range of environmental factors impact on drug use, including price and availability of both licit and illicit drugs Other environmental factors include prenatal problems, early childhood experiences, family relationship and bonding, and early educational opportunities. Other environmental factors include prenatal problems, early childhood experiences, family relationship and bonding, and early educational opportunities. Cultural norms around drug use also act as powerful determinants of the use of both licit and illicit substances Cultural norms around drug use also act as powerful determinants of the use of both licit and illicit substances

17 Psychoactive drugs are generally defined as substances that alter: mood mood cognition (thoughts) cognition (thoughts) behaviour behaviour Psychoactive drugs (1)

18 Psychoactive drugs (2) Affect mental processes and behaviour Affect mental processes and behaviour Affect thought processes and actions Affect thought processes and actions Alter perceptions of reality Alter perceptions of reality Change level of alertness, response time, and perception of the world Change level of alertness, response time, and perception of the world Achieve effects by interacting with the central nervous system (CNS) Achieve effects by interacting with the central nervous system (CNS) Carmichael (2001)

19 Psychoactive drug use Is a common activity Is a common activity Is part of a range of human behaviours Is part of a range of human behaviours Can be classified in many ways, including legal status, drug effects Can be classified in many ways, including legal status, drug effects Alters mood or consciousness, although there are other ways to achieve this: Alters mood or consciousness, although there are other ways to achieve this: e.g., skydiving, meditation, extreme (and non- extreme) sports, sex. Children, for example, love to alter their consciousness by spinning around. e.g., skydiving, meditation, extreme (and non- extreme) sports, sex. Children, for example, love to alter their consciousness by spinning around.

20 Views about AOD-related issues experience experience culture culture education education religion religion Our thinking about alcohol and other drug (AOD) related issues is informed by factors such as: family / environment legislation

21 Psychoactive drugs may be classified according to their: 1. Status legal legal chemical chemical medical medical social social 2. Action and properties depressant stimulant hallucinogenic etc. Drug classifications

22 Classifying psychoactive drugs DepressantsStimulantsHallucinogens AlcoholAmphetamines LSD, DMT BenzodiazepinesMethamphetamineMescaline OpioidsCocainePCP SolventsNicotineKetamine BarbituratesKhat Cannabis (high doses) Cannabis (low doses) Caffeine Magic mushrooms MDMAMDMA

23 Drug use and health Patients with drug problems: often have multiple health and social problems often have multiple health and social problems expect doctors to ask and provide information about alcohol and drug issues – failure to inquire may lead to medical malpractice in some situations expect doctors to ask and provide information about alcohol and drug issues – failure to inquire may lead to medical malpractice in some situations

24 Types of problems (1) Different patterns of drug use result in different types of problems Different patterns of drug use result in different types of problems Because individuals have different genetic make ups and early experiences, they may respond differently to drugs and have a different risk for drug abuse and dependence Because individuals have different genetic make ups and early experiences, they may respond differently to drugs and have a different risk for drug abuse and dependence Drug use may affect all areas of a patients life, and problems are not restricted to dependent drug use Drug use may affect all areas of a patients life, and problems are not restricted to dependent drug use

25 Types of problems: Thorleys Model Intoxication Accidents / injury Poisoning / hangovers Absenteeism High-risk behaviour Regular / excessive Use Health Finances Relationships Child neglect Dependence Impaired control Drug-centred behaviour Isolation / social problems Withdrawal symptoms and psychiatric problems Health Problems I R D

26 Drug Route, effects, actions, purity, potency, quality Form, price, availability, interaction with other drugs, previous experience Physical / emotional reaction, mood, current health, age, tolerance, knowledge, beliefs, memories, expectations Individual Where, when, who, how, employment, social context, supply, peers, legality, culture, media, advertising, availability Interactive Model of Drug Use The Drug Use Experience Environment

27 Important terminology 1.Harmful use 2.Physical dependence vs. addiction 3.Psychological craving 4.Tolerance 5.Withdrawal symptoms 6.Neurotransmitters and receptors

28 What is harmful use? (ICD-10) A pattern of psychoactive substance use that is damaging to physical and / or mental health.

29 What is drug addiction? Drug addiction is a complex illness characterised by compulsive, and at times, uncontrollable drug craving, seeking, and use that persist even in the face of extremely negative consequences. (NIDA, 1999)

30 Characteristics of addiction Compulsive behaviour Compulsive behaviour Behaviour is reinforcing (rewarding or pleasurable) Behaviour is reinforcing (rewarding or pleasurable) Loss of control in limiting intake Loss of control in limiting intake (NIDA;

31 Psychological craving Psychological craving is a strong desire or urge to use drugs. Cravings are most apparent during drug withdrawal.

32 Tolerance A state in which a person no longer responds to a drug as they did before, and a higher dose is required to achieve the same effect.

33 A period during which somebody addicted to a drug or other addictive substance reduces their use or stops taking it, causing the person to experience painful or uncomfortable symptoms OR A person takes a similar substance in order to avoid experiencing the effects described above. Withdrawal (1)

34 Withdrawal (2) When a drug is removed, physical and / or mental disturbances may occur, including: Physical symptoms Physical symptoms Emotional problems Emotional problems Cognitive and attention deficits Cognitive and attention deficits Aggressive behavior Aggressive behavior Hallucinations Hallucinations Convulsions Convulsions Death Death

35 DSM IV criteria for substance dependence Three or more of the following occurring at any time during the same 12 month period: Tolerance Tolerance Withdrawal Withdrawal Substance taken in larger amounts over time Substance taken in larger amounts over time Persistent desire and unsuccessful efforts to cut down or stop Persistent desire and unsuccessful efforts to cut down or stop A lot of time and activities spent trying to get the drug A lot of time and activities spent trying to get the drug Disturbance in social, occupational, or recreational functioning Disturbance in social, occupational, or recreational functioning Continued use in spite of knowledge of the damage it is doing to the user or others Continued use in spite of knowledge of the damage it is doing to the user or others (DSM-IV-TR, American Psychiatric Association, 2000.)

36 ICD-10 criteria for dependence Dependence: 3 or more of the following: (a) strong desire or sense of compulsion to take the substance; (b) difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use; (c) a physiological withdrawal state; (d) evidence of tolerance; (e) progressive neglect of alternative pleasures or interests (f) persisting with substance use despite clear evidence of overtly harmful consequences

37 In this training, addiction will be the term used to refer to the pattern of continued use of drugs despite pathological behaviours and other negative outcomes In this training, addiction will be the term used to refer to the pattern of continued use of drugs despite pathological behaviours and other negative outcomes Dependence will only be used to refer to physical dependence on the substance as indicated by tolerance and withdrawal as described above Dependence will only be used to refer to physical dependence on the substance as indicated by tolerance and withdrawal as described above To avoid confusion

38 Addiction = Brain Disease Addiction is a brain disease that is chronic and relapsing in nature. (NIDA;

39 A major reason people take a drug is they like what it does to their brains A major reason people take a drug is they like what it does to their brains

40 How the reward system works

41

42 Time (min) % of Basal DA Output NAc shell Empty Box Feeding Source: Di Chiara et al. FOOD Natural rewards elevate dopamine levels

43 Activating the system with drugs (NIDA;

44 Time After Cocaine % of Basal Release DA DOPAC HVA Accumbens COCAINE hr Time After Nicotine % of Basal Release Accumbens Caudate NICOTINE Source: Shoblock and Sullivan; Di Chiara and Imperato Effects of Drugs on Dopamine Release Time After Methamphetamine % Basal Release METHAMPHETAMINE 0123hr Accumbens

45 Why cant people just stop drug use? When people first try drugs, it is usually a voluntary decision, but after using the drug for a while, it is no longer voluntary. Why cant people stop?

46

47

48 Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH) Abuser After Protracted Abstinence Normal Control METH Abuser (1 month detox) METH Abuser (24 months detox) 0 3 ml/gm (Volkow, N.D., et al Journal of Neuroscience 21, )

49 Their Brains have been Re-Wired by Drug Use Their Brains have been Re-Wired by Drug Use Because…

50 Prolonged drug use changes the brain in fundamental and long-lasting ways! Why cant people just stop drug use?

51 Compulsive Drug Use (Addiction) Compulsive Drug Use (Addiction) Voluntary Drug Use Voluntary Drug Use

52 Its Not Just Addiction is, Fundamentally, A Brain Disease Brain Disease A Brain Disease A Brain Disease...BUT

53 DRUGS BRAIN MECHANISMS BEHAVIOR ENVIRONMENT HISTORICAL ENVIRONMENTAL - previous history - expectation - learning - social interactions - stress - conditioned stimuli - genetics - circadian rhythms - disease states - gender PHYSIOLOGICAL

54 Questions?Comments? ? ? ?

55 Post-assessment Please respond to the post-assessment questions in your workbook. (Your responses are strictly confidential.) 10 Min.

56 Thank you for your time! End of Workshop 1

57 Volume C, Module 1, Workshop 2: Alcohol & Benzodiazepines; Medical Issues, Detoxification Approaches, Pharmacotherapies Volume C, Module 1, Workshop 2: Alcohol & Benzodiazepines; Medical Issues, Detoxification Approaches, Pharmacotherapies Treatnet Training Volume C: Module 1 – Updated 18 October 2007

58 Training objectives At the end of this training you know: 1.Acute and chronic effects of alcohol and benzodiazepines, the medical and psychiatric dangers associated with intoxication, overdose, withdrawal, and interactions with other substances 2.Treatment protocols to treat intoxication and overdose 3.Withdrawal approaches and protocols 4.Necessary treatments following detoxification 5.Proper setting and support services needed to properly conduct withdrawal treatments

59 Alcohol

60 Acute alcohol-related harms Physical injury and psychological harms and death arise from: Falls Falls Physical assaults Physical assaults Sexual assaults Sexual assaults Domestic violence Domestic violence Traffic accidents Traffic accidents Occupational & machinery injuries Occupational & machinery injuries Fires Fires Drowning Drowning Child abuse Child abuse Unprotected sex leading to STDs and HIV Unprotected sex leading to STDs and HIV Overdose Overdose Comorbidity Comorbidity Dehydration Dehydration Sleep disturbances Sleep disturbances Raised blood pressure Raised blood pressure Shortness of breath Shortness of breath

61 Alcohol Still the most popular drug Still the most popular drug In some societies over 80% of population drinks In some societies over 80% of population drinks 8% drink daily, peak in males +60 yrs (23%). 40% drink weekly. 8% drink daily, peak in males +60 yrs (23%). 40% drink weekly. At-risk drinking now defined as: At-risk drinking now defined as: risks of harm in the long term (chronic harm) risks of harm in the long term (chronic harm) risks of harm in the short term (acute harm) risks of harm in the short term (acute harm)

62 A standard drink

63 Risky drinking levels (for chronic harm)

64 Alcohol-induced memory loss Teenagers (28.4%) were most likely to have a memory loss incident following drinking: Teenagers (28.4%) were most likely to have a memory loss incident following drinking: 4.4% reported blackouts occurring on weekly basis 4.4% reported blackouts occurring on weekly basis 10.9% reported blackouts on a monthly basis 10.9% reported blackouts on a monthly basis Memory loss occurred after drinking for: Memory loss occurred after drinking for: 12% male drinkers aged > 40 years 12% male drinkers aged > 40 years 7% female drinkers aged > 40 years 7% female drinkers aged > 40 years 20% - 30% of all other age groups 20% - 30% of all other age groups

65 Predisposing factors for high-risk drinking Family history of alcohol problems Family history of alcohol problems Childhood problem behaviours related to impulse control Childhood problem behaviours related to impulse control Poor coping responses in the face of stressful life events Poor coping responses in the face of stressful life events Depression, divorce, or separation Depression, divorce, or separation Drinking partner Drinking partner Working in a male-dominated environment Working in a male-dominated environment

66 Concurrent mental health problems Alcohol may: exacerbate existing mental health problems exacerbate existing mental health problems interact with prescribed medications interact with prescribed medications reduce or exacerbate the effect of certain medications reduce or exacerbate the effect of certain medications reduce patient compliance with treatment regimens reduce patient compliance with treatment regimens

67 Women and alcohol Women are more susceptible to the effects of alcohol due to: smaller physical size smaller physical size decreased blood volume decreased blood volume lower body water to fat ratio lower body water to fat ratio reduced ADH activity in gastric mucosa (hence reduced stomach metabolism of alcohol). reduced ADH activity in gastric mucosa (hence reduced stomach metabolism of alcohol). Resulting in: earlier development of organ damage earlier development of organ damage increased risk of intoxication related harms; e.g., assault, injury. increased risk of intoxication related harms; e.g., assault, injury.

68 Fetal Alcohol Syndrome (FAS) Increasing prevalence of risky drinking by young women has raised concerns about fetal alcohol syndrome / effects.

69 FAS Diagnosis 1. Prenatal or postnatal growth retardation 2. Brain dysfunction (intellectual retardation, poor muscle tone, irritability) 3. Facial dysmorphology Microcephaly Microcephaly Microphthalmia (smallness of the eye) Microphthalmia (smallness of the eye) Thin upper lip Thin upper lip

70 Pharmacokinetics Rapidly absorbed into blood by stomach (20%) and small intestine (80%) 2% excreted unchanged in sweat, breath, & urine Distributed in body fluids (not fat) 1 standard drink per hour raises BAC by about 0.01–0.03 g%. 5 minutes to affect brain Metabolised by liver (95% – 99%) alcohol acetaldehyde acetic acid & H 2 O CO 2

71 Alcohol: Effects on the brain No single receptor. Alcohol interacts with and alters function of many different cellular components. No single receptor. Alcohol interacts with and alters function of many different cellular components. Primary targets are GABA, NMDA glutamate, serotonin, and ATP receptors Primary targets are GABA, NMDA glutamate, serotonin, and ATP receptors Stimulates dopamine and opioid systems Stimulates dopamine and opioid systems Effects of chronic consumption are opposite to acute because of homeostatic compensation Effects of chronic consumption are opposite to acute because of homeostatic compensation

72 Alcohol Metabolism National Institute on Alcohol Abuse and Alcoholism (NIAAA)

73 Effects of alcohol intoxication

74 Types of problems Intoxication Withdrawal Withdrawal Craving Craving Obsessive Obsessive Cognitive Conflict Cognitive Conflict Loss of Control Loss of Control Withdrawal Withdrawal Craving Craving Obsessive Obsessive Cognitive Conflict Cognitive Conflict Loss of Control Loss of Control Regular Use · Dependence

75 Types of problems: Clinical samples Intox. Regular Use Dependence

76 Binge drinking Binge drinking can lead to: increased risk taking increased risk taking poor judgement / decision making poor judgement / decision making Misadventure / accidents Misadventure / accidents increased risky sexual behaviour increased risky sexual behaviour increased violence increased violence suicide suicide

77 Harms associated with high-risk alcohol use Hypertension, CVA Hypertension, CVA Cardiomyopathy Cardiomyopathy Peripheral neuropathy Peripheral neuropathy Impotence Impotence Cirrhosis and hepatic or bowel carcinomas Cirrhosis and hepatic or bowel carcinomas Cancer of lips, mouth, throat, and esophagus Cancer of lips, mouth, throat, and esophagus Cancer of breast Cancer of breast Fetal alcohol syndrome Fetal alcohol syndrome

78 Alcohol-related brain injury Cognitive impairment may result from consumption levels of >70 grams per day Cognitive impairment may result from consumption levels of >70 grams per day Thiamine deficiency leads to: Thiamine deficiency leads to: Wernickes encephalopathy Wernickes encephalopathy Korsakoffs psychosis Korsakoffs psychosis Frontal lobe syndrome Frontal lobe syndrome Cerebellar degeneration Cerebellar degeneration Trauma Trauma

79 Interventions and treatment for alcohol-related problems Screening and assessment individualised interventions Screening and assessment individualised interventions Brief intervention and harm reduction strategies Brief intervention and harm reduction strategies Withdrawal management Withdrawal management Relapse prevention / goal-setting strategies Relapse prevention / goal-setting strategies Controlled drinking programs Controlled drinking programs Residential programs Residential programs Self-help groups Self-help groups

80 Brief Intervention Consider the patients: perspective on drinking perspective on drinking attitudes towards drinking goals attitudes towards drinking goals significant others significant others short-term objectives short-term objectivesProvide: information on standard drinks, risks, and risk levels information on standard drinks, risks, and risk levels encouragement to identify positive alternatives to drinking encouragement to identify positive alternatives to drinking self-help manuals self-help manuals follow-up session follow-up session

81 Two steps towards alcohol brief intervention (BI) 1. Screening For example, the alcohol AUDIT, a 10-item questionnaire For example, the alcohol AUDIT, a 10-item questionnaire 2. Intervention Information Information Brief counselling Brief counselling Advice Advice Referral (if required) Referral (if required)

82 AUDIT – The FLAGS approach After administering the AUDIT, useFLAGS: Feedback results Feedback results Listen to patient concerns Listen to patient concerns Provide Alcohol education and information Provide Alcohol education and information Goals of treatment – identify and plan Goals of treatment – identify and plan Strategies discussed and implemented Strategies discussed and implemented

83 Benefits of cutting down or cutting out: save money save money be less depressed be less depressed lose weight lose weight less hassles for family less hassles for family have more energy have more energy sleep better sleep better better physical shape better physical shape Harm-minimising strategies Reduce the risk of: liver disease cancer brain damage high blood pressure accidents injury legal problems

84 Choosing a treatment option

85 Withdrawal Usually occurs 6– 24 hours after last drink: Tremor Tremor anxiety and agitation anxiety and agitation Sweating Sweating nausea and vomiting nausea and vomiting Headache Headache sensory disturbances hallucinations sensory disturbances hallucinations Severity depends on: pattern, quantity and duration of use pattern, quantity and duration of use previous withdrawal history previous withdrawal history patient expectations patient expectations physical and psychological wellbeing of the patient (illness or injury) physical and psychological wellbeing of the patient (illness or injury) other drug use/dependence other drug use/dependence the setting in which withdrawal takes place the setting in which withdrawal takes place

86 Progress of Alcohol Withdrawal from Time of Last Drink (Source: deCrespigny & Cusack (2003) Adapted from NSW Health Detoxification Clinical Practice Guidelines (2000–2003))

87 Treatment of alcohol withdrawal symptoms Diazepam Diazepam Thiamine & multivitamins Thiamine & multivitamins Antiemetic Antiemetic Analgesia (e.g., paracetamol) Analgesia (e.g., paracetamol) Antidiarrhoeal Antidiarrhoeal Medications for Symptomatic Treatment

88 Post-withdrawal management Treatment options: retain in treatment, ongoing management retain in treatment, ongoing management seek referral seek referralConsiderations: patients wants (abstinence or reduced consumption, remaining your patient) patients wants (abstinence or reduced consumption, remaining your patient) severity of problems severity of problemsPharmacotherapies: acamprosate acamprosate naltrexone naltrexone disulfiram disulfiram

89 Naltrexone and Acamprosate Effective. Effective. Work well with variety of supportive treatments, e.g., brief intervention, CBT, supportive group therapy. Work well with variety of supportive treatments, e.g., brief intervention, CBT, supportive group therapy. Start following alcohol withdrawal. Proven efficacy where goal is abstinence, uncertain with goal of moderation. Start following alcohol withdrawal. Proven efficacy where goal is abstinence, uncertain with goal of moderation. No contraindication while person is still drinking, although efficacy uncertain. No contraindication while person is still drinking, although efficacy uncertain. Generally safe and well tolerated. Generally safe and well tolerated.

90 Clinical guidelines Naltrexone 50 mg daily: indicated especially where strong craving for alcohol after a priming dose indicated especially where strong craving for alcohol after a priming dose likelihood of lapse progressing to relapse likelihood of lapse progressing to relapse LFTs < x3 above normal LFTs < x3 above normal side effects: nausea in the first few days side effects: nausea in the first few days Acamprosate 600 mg (2 tabs) tds: indicated especially when susceptible to drinking cues or drinking triggered by withdrawal symptoms indicated especially when susceptible to drinking cues or drinking triggered by withdrawal symptoms low potential for drug interactions low potential for drug interactions need normal renal function need normal renal function side effects: diarrhoea, headache, nausea, itch side effects: diarrhoea, headache, nausea, itch

91 Disulfiram Acetaldehyde dehydrogenase inhibitor – 200 mg daily Acetaldehyde dehydrogenase inhibitor – 200 mg daily unpleasant reaction with alcohol ingestion (depending on dose) unpleasant reaction with alcohol ingestion (depending on dose) Indications: alcohol dependence + goal of abstinence + need for external aid to abstinence Indications: alcohol dependence + goal of abstinence + need for external aid to abstinence Controlled trials: abstinence rate in first 3–6 months Controlled trials: abstinence rate in first 3–6 months Best results with supervised ingestion & contingency management strategies Best results with supervised ingestion & contingency management strategies Caution when using with patients who have significant symptoms of depression Caution when using with patients who have significant symptoms of depression

92 Benzodiazepines: the opium of the massesBenzodiazepines: the opium of the masses (Source: Malcolm Lader, Neuroscience, 1978) Benzodiazepines

93 Benzodiazepines: History 1950s Invented by Swiss chemists who identified its sedative effects 1950s–60s Chlordiazepoxide (Librium) marketed as a safer alternative to barbiturates; along with newer benzodiazepines (BZDs), promoted as having no dependence-inducing properties! 1970s–80sBZDs most commonly prescribed drug class in the world 1990s on Some decline in the number of prescriptions due to problems related to dependence and reduced therapeutic value. Generally safer than barbiturates; problems are with longer term and polydrug use million prescriptions dispensed

94 General medical / psychiatric indications for benzodiazepine use Anxiolytic – chronic / phobic anxiety & panic attacks Anxiolytic – chronic / phobic anxiety & panic attacks Sedative and hypnotic – sleep disturbance & anaesthesia / premedication Sedative and hypnotic – sleep disturbance & anaesthesia / premedication Anticonvulsant – status epilepticus, myoclonic & photic epilepsy Anticonvulsant – status epilepticus, myoclonic & photic epilepsy Muscle relaxant – muscle spasm / spasticity Muscle relaxant – muscle spasm / spasticity Alcohol withdrawal Alcohol withdrawal

95 Exercise: Case study After the recent and unexpected death of her husband from an MI, Shirley, aged 62, presented for you to check her cardiac state as she fears a similar fate to her husbands. She is afraid to go out alone, and she fears going to sleep as she is scared she will not wake up. She experiences occasional non-radiating chest pain. She has been taking sleeping tablets for several years and finds that they are now no longer working. What would be an appropriate treatment option and plan for Shirley?

96 Patterns of use BZDs are one of the most prescribed drugs BZDs are one of the most prescribed drugs 4% of all prescriptions from general practitioners are for benzodiazepines (BZDs) 4% of all prescriptions from general practitioners are for benzodiazepines (BZDs) Predictors for BZD prescription include: Predictors for BZD prescription include: being female being female being elderly being elderly being an established patient being an established patient attending a busy doctor, or a doctor in inner urban area attending a busy doctor, or a doctor in inner urban area Over 40% of prescriptions given to people >70 years old Over 40% of prescriptions given to people >70 years old Night time use tends to increase with age Night time use tends to increase with age 58% of current users report daily use for >6 months 58% of current users report daily use for >6 months

97 BZDs and long-term use Long-term use is common and associated with: Long-term use is common and associated with: altered use patterns (from nighttime to daytime use) altered use patterns (from nighttime to daytime use) excessive sedation excessive sedation cognitive impairment cognitive impairment increased risk of accidents increased risk of accidents adverse sleep effects adverse sleep effects dependence and withdrawal (even at therapeutic doses) dependence and withdrawal (even at therapeutic doses) BZDs have an additive effect with alcohol / other CNS depressants, increasing the risk of harm BZDs have an additive effect with alcohol / other CNS depressants, increasing the risk of harm BZDs have limited long-term efficacy BZDs have limited long-term efficacy

98 BZD and illicit drug use Illicit BZD use is usually oral, although around 5% are likely to inject (usually males) Illicit BZD use is usually oral, although around 5% are likely to inject (usually males) Often 2 nd drug of choice for illicit drug users, as BZDs assist withdrawal from opioids, stimulants, and alcohol Often 2 nd drug of choice for illicit drug users, as BZDs assist withdrawal from opioids, stimulants, and alcohol Estimated around 70% of people using >50 mg per day are polydrug users, who tend to: Estimated around 70% of people using >50 mg per day are polydrug users, who tend to: be younger be younger have higher daily doses and higher lifetime exposure have higher daily doses and higher lifetime exposure use in combination with other CNS depressants to increase intoxication use in combination with other CNS depressants to increase intoxication prefer fast-acting BZDs (diazepam, flunitrazepam) prefer fast-acting BZDs (diazepam, flunitrazepam) may convert form to enable injection may convert form to enable injection

99 Benzodiazepines: Half-life Benzodiazepines Half-life (hrs) 2 [active metabolite] Appr. Equivalent Oral dosages (mg)3 Alprazolam (Xanax, Xanor, Tafil) Diazepam(Valium)20-100[36-200]10 Clonazepam (Klonopin, Rivotril)

100 Pharmacodynamics Rapidly absorbed orally (slower rate of absorption IM) Rapidly absorbed orally (slower rate of absorption IM) Lipid soluble - differences determine rate of passage through blood brain barrier, i.e., Lipid soluble - differences determine rate of passage through blood brain barrier, i.e., lipophilic speed of onset lipophilic speed of onset Duration of action variable – Duration of action variable – lipophilic duration of action due to distribution in adipose tissue lipophilic duration of action due to distribution in adipose tissue

101 Metabolism Metabolised in the liver – mostly oxidative transformation prior to conjugation with glucuronic acid for urinary excretion Metabolised in the liver – mostly oxidative transformation prior to conjugation with glucuronic acid for urinary excretion Elimination half life (drug & active metabolites) ranges from 8 – >60 hours, if short half life & no active metabolites, it rapidly attains steady state with minimal accumulation Elimination half life (drug & active metabolites) ranges from 8 – >60 hours, if short half life & no active metabolites, it rapidly attains steady state with minimal accumulation

102 Neurotransmission Potentiate neurotransmission mediated by GABA (main inhibitory neurotransmitter), therefore neurons are more difficult to excite Potentiate neurotransmission mediated by GABA (main inhibitory neurotransmitter), therefore neurons are more difficult to excite Specific neuronal membrane receptors for BZD closely associated with synaptic GABA receptors Specific neuronal membrane receptors for BZD closely associated with synaptic GABA receptors Receptors distributed through CNS, concentrated in reticular formation & limbic systems, also peripheral binding sites Receptors distributed through CNS, concentrated in reticular formation & limbic systems, also peripheral binding sites Further understanding of the effects of BZDs on receptor subgroups may lead to the development of non-sedating anxiolytic BZDs Further understanding of the effects of BZDs on receptor subgroups may lead to the development of non-sedating anxiolytic BZDs

103 Effects: Low dose Short term: Sedation Sedation Anxiety relief Anxiety relief Anticonvulsant properties Anticonvulsant properties Can usually attend daily business (though should not drive in first 2 weeks of treatment) Can usually attend daily business (though should not drive in first 2 weeks of treatment) Other effects: Drowsiness, lethargy, fatigue Drowsiness, lethargy, fatigue Impaired concentration, coordination, memory Impaired concentration, coordination, memory Reduced ability to think and learn Reduced ability to think and learn Clumsiness, ataxia Clumsiness, ataxia Depression Depression Mood swings Mood swings Blurred vision and / or vertigo Blurred vision and / or vertigo Light-headedness Light-headedness Nausea, constipation, dry mouth, loss of appetite Nausea, constipation, dry mouth, loss of appetite

104 Effects: High dose Short term Sedation Sedation Intoxication Intoxication Drowsiness Drowsiness Other effects Paradoxical excitement Paradoxical excitement Mood swings Mood swings Hostile and erratic behaviour Hostile and erratic behaviour Toxicity Performance deficits Performance deficits Emotional blunting Emotional blunting Muscle weakness Muscle weakness Sensitivity Sensitivity Potentiates other drugs Potentiates other drugs Euphoria, hypomania Euphoria, hypomania

105 Drug + alcohol interactions CNS depressants, CNS depressants, e.g., benzodiazepines Antipsychotics, antidepressants Antipsychotics, antidepressants Opioid analgesics, antihistamines (some) Opioid analgesics, antihistamines (some) Hypoglycaemics (chlorpropamide), metronidazole, cephalosporins (some) Hypoglycaemics (chlorpropamide), metronidazole, cephalosporins (some) Confusion, depressed respiration Decreased metabolism, toxicity & CNS depression CNS depression Facial flushing, headache

106 Overdose Benzodiazepines are the most commonly implicated drug in overdose cases Benzodiazepines are the most commonly implicated drug in overdose cases On their own, unlikely to cause death despite causing respiratory depression On their own, unlikely to cause death despite causing respiratory depression Serious / potentially fatal implications when used in combination with other CNS depressants Serious / potentially fatal implications when used in combination with other CNS depressants

107 Overdose response Overdose depresses the conscious state and respiratory system. Airway management and assisted ventilation is necessary. Flumazenil® a BZD antagonist which reverses BZD overdose, though contraindicated outside the emergency department a BZD antagonist which reverses BZD overdose, though contraindicated outside the emergency department precipitates seizures in: precipitates seizures in: chronic BZD users chronic BZD users pre-existing epilepsy pre-existing epilepsy tricyclic antidepressant users tricyclic antidepressant users concurrent amphetamine or cocaine users concurrent amphetamine or cocaine users

108 Assessment Review BZD medication Review BZD medication initial reasons for use initial reasons for use type of BZD, response to, and patterns of use type of BZD, response to, and patterns of use side-effects reported or observed side-effects reported or observed current / past withdrawal history and symptoms current / past withdrawal history and symptoms Obtain physical history (concurrent medical problems) Obtain physical history (concurrent medical problems) Mental health history (e.g., depression) Mental health history (e.g., depression) Other drug (and alcohol / prescription drug) use Other drug (and alcohol / prescription drug) use Discuss options Discuss options risks of continued and prolonged use risks of continued and prolonged use withdrawal potential / risks, management options withdrawal potential / risks, management options

109 1. Low dose dependence occurs among women and elderly prescribed low doses over long time periods (up to 40% experience withdrawal symptoms) 2. High dose dependence occurs among polydrug users Dependence Two groups of patients are especially likely to develop dependence.

110 Withdrawal 40% of people on long-term therapeutic BZD doses will experience withdrawal if abruptly ceased 40% of people on long-term therapeutic BZD doses will experience withdrawal if abruptly ceased Symptoms occur within 2 short-acting to 7 day long-acting forms Symptoms occur within 2 short-acting to 7 day long-acting forms BZD withdrawal: BZD withdrawal: is not life-threatening & usually protracted is not life-threatening & usually protracted initial symptoms / problems re-emerge on cessation initial symptoms / problems re-emerge on cessation issues usually more complicated on cessation issues usually more complicated on cessation Seizures uncommon (unless high dose use or abrupt withdrawal, + alcohol use) Seizures uncommon (unless high dose use or abrupt withdrawal, + alcohol use) Two main groups of users: Two main groups of users: prescribed (older women) prescribed (older women) high level, erratic polydrug use high level, erratic polydrug use

111 Withdrawal severity Severity of withdrawal is dependent on: pattern and extent of use (duration, quantity, type (half-life)) pattern and extent of use (duration, quantity, type (half-life)) withdrawal experience (prior symptoms, success, complications) withdrawal experience (prior symptoms, success, complications) coexisting physical / mental health problems coexisting physical / mental health problems

112 3 Areas of BZD withdrawal Anxiety and anxiety-related symptoms anxiety, panic attacks, hyperventilation, tremor anxiety, panic attacks, hyperventilation, tremor sleep disturbance, muscle spasms, anorexia, weight loss sleep disturbance, muscle spasms, anorexia, weight loss visual disturbance, sweating visual disturbance, sweating dysphoria dysphoria Perceptual distortions hypersensitivity to stimuli hypersensitivity to stimuli abnormal body sensations abnormal body sensations depersonalisation/derealisation depersonalisation/derealisation Major events seizures (grand mal type) seizures (grand mal type) precipitation of psychosis precipitation of psychosis

113 Withdrawal management Obtain an accurate consumption history Obtain an accurate consumption history Calculate diazepam equivalent and substitute. Reduce gradually over 6–8 weeks (or longer, e.g., 3–4 months) Calculate diazepam equivalent and substitute. Reduce gradually over 6–8 weeks (or longer, e.g., 3–4 months) Reduce dose by a fixed rate at weekly intervals (usually 10%–20% initially, then 5%–10% / week, or slower when dose at 15 mg or less). Reduce dose by a fixed rate at weekly intervals (usually 10%–20% initially, then 5%–10% / week, or slower when dose at 15 mg or less). Supervision of long-term BZD reductions (3-4 months) Supervision of long-term BZD reductions (3-4 months) Dose at regular times Dose at regular times Regularly review and titrate dose to match symptoms Regularly review and titrate dose to match symptoms If symptoms re-emerge, dose may be plateaued for 1–2 weeks, or increased before reduction resumed If symptoms re-emerge, dose may be plateaued for 1–2 weeks, or increased before reduction resumed Provide support, not pharmacological alternatives for conditions such as insomnia and anxiety. Provide support, not pharmacological alternatives for conditions such as insomnia and anxiety.

114 Outpatient withdrawal protocol Consider outpatient withdrawal management: Consider outpatient withdrawal management: if willing, committed, compliant, and has adequate social supports if willing, committed, compliant, and has adequate social supports if taking < 50 mg diazepam equivalent or therapeutic doses if taking < 50 mg diazepam equivalent or therapeutic doses if no previous history of complicated withdrawal if no previous history of complicated withdrawal if able to attend weekly reviews if able to attend weekly reviews Develop an individualised withdrawal plan considering: Develop an individualised withdrawal plan considering: psychosocial factors psychosocial factors coping skills coping skills previous attempts previous attempts counselling / referral needs counselling / referral needs

115 Inpatient withdrawal protocol Inpatient withdrawal management is necessary if the patient: is using > 50 mg diazepam equivalent for >14 days is using > 50 mg diazepam equivalent for >14 days has a history of alcohol or other drug use or dependence has a history of alcohol or other drug use or dependence has concurrent medical or psychiatric problem has concurrent medical or psychiatric problem has a history of withdrawal seizures has a history of withdrawal seizures if significant symptoms are predicted if significant symptoms are predicted is in an unstable social situation is in an unstable social situation has previous poor compliance / doubtful motivation has previous poor compliance / doubtful motivation is in concurrent methadone stabilisation is in concurrent methadone stabilisation

116 Drug interactions BZDs either potentiate / increase effects or interfere with metabolism or absorption of : alcohol alcohol antidepressants and antihistamines antidepressants and antihistamines disulfiram, cimetidine, erythromycin disulfiram, cimetidine, erythromycin anticonvulsants anticonvulsants anticoagulants, oral diabetic agents anticoagulants, oral diabetic agents cisapride cisapride

117 Exercise: Case study Meg, a 47-year-old woman, always has alcohol on her breath and frequently falls. She moved into the suburb a few months ago and is well known at the local liquor shop and hotel. She denied alcohol use until a recent fracture and hospital admission. Since her discharge, she has started drinking again, mostly spirits. She presents to you late one afternoon seeking benzodiazepines. As her doctor, how will you respond? If her alcohol use continues, how can harm be reduced?

118 Thank you for your time! End of Workshop 2

119 Questions?Comments? ? ? ?

120 Workshop 3: Psychostimulants, Volatile Substances, and Cannabis: Medical Issues and Treatment Approaches

121 Training objectives At the end of this training you will: Understand acute and chronic effects of psychostimulants, volatile substances, and cannabis and the medical and psychiatric dangers associated with intoxication, overdose, withdrawal, and interactions with other substances. Understand acute and chronic effects of psychostimulants, volatile substances, and cannabis and the medical and psychiatric dangers associated with intoxication, overdose, withdrawal, and interactions with other substances. Know treatment protocols to treat intoxication and overdose Know treatment protocols to treat intoxication and overdose Know withdrawal approaches and protocols Know withdrawal approaches and protocols Know about necessary treatments following detoxification Know about necessary treatments following detoxification Know proper setting and support services needed to properly conduct treatments Know proper setting and support services needed to properly conduct treatments

122 Stimulants CRACK METHAMPHETAMINE COCAINE

123 Stimulants Description: A group of synthetic and plant- derived drugs that increase alertness and arousal by stimulating the central nervous system. Although MDMA (ecstasy) has some hallucinogenic properties, it is often classified as a stimulant Medical Uses: Short-term treatment of obesity, narcolepsy, and hyperactivity in children Method of Use: Intravenous, intranasal, oral, smoking

124 Types of stimulant drugs Amphetamine Type Stimulants (ATS) Amphetamine Amphetamine Dexamphetamine Dexamphetamine Methylphenidate Methylphenidate Methamphetamine (speed, crystal, ice, yaba, shabu) Methamphetamine (speed, crystal, ice, yaba, shabu)

125 Types of stimulant drugs Cocaine Products Cocaine Products Cocaine powder (generally sniffed, injected, smoked on foil) Cocaine powder (generally sniffed, injected, smoked on foil) Crack (smoked) Crack (smoked)

126 Types of stimulant drugs Methyldioxymethamphetamine (MDMA) (A synthetic drug with psychostimulant and hallucinogenic properties) Commonly referred to as ecstasy. Sold in tablet form Commonly referred to as ecstasy. Sold in tablet form Estimated to be 10 million users worldwide Estimated to be 10 million users worldwide

127 According to surveys and estimates by WHO and UNODC, ATS is the most widely used category of illicit drugs in the world except for cannabis. According to surveys and estimates by WHO and UNODC, ATS is the most widely used category of illicit drugs in the world except for cannabis. Worldwide, there an estimated 26 million or more regular users of amphetamine, methamphetamine, or ecstasy, as compared to approximately 16 million heroin users and 14 million cocaine users. Worldwide, there an estimated 26 million or more regular users of amphetamine, methamphetamine, or ecstasy, as compared to approximately 16 million heroin users and 14 million cocaine users. Methamphetamine accounts for over 90% of the ATS used worldwide Methamphetamine accounts for over 90% of the ATS used worldwide Scope of the ATS problem worldwide

128 Methamphetamine vs. cocaine Cocaine half-life: 2 hours Cocaine half-life: 2 hours Methamphetamine half-life: 10 hours Methamphetamine half-life: 10 hours Cocaine paranoia: hours following drug cessation Cocaine paranoia: hours following drug cessation Methamphetamine paranoia: 7-14 days Methamphetamine paranoia: 7-14 days Methamphetamine psychosis - May require medication / hospitalisation and may not be reversible Methamphetamine psychosis - May require medication / hospitalisation and may not be reversible Neurotoxicity: Appears to be more profound with amphetamine-like substances Neurotoxicity: Appears to be more profound with amphetamine-like substances

129 Acute stimulant effects Psychological Increased energy Increased energy Increased clarity Increased clarity Increased competence Increased competence Heightened feelings of sexuality Heightened feelings of sexuality Increased sociability Increased sociability Improved mood Improved mood Powerful rush of euphoria - freebase and intravenous only Powerful rush of euphoria - freebase and intravenous only

130 Acute stimulant effects Physical Increased heart rate Increased heart rate Increased pupil size Increased pupil size Increased body temperature Increased body temperature Increased respiration Increased respiration Cardiac arrhythmias Cardiac arrhythmias Constriction of small blood vessels Constriction of small blood vessels Decreased appetite Decreased appetite Decreased need for sleep Decreased need for sleep

131 Chronic stimulant effects Physical Weight loss / anorexia Weight loss / anorexia Sleep deprivation Sleep deprivation Respiratory system disease Respiratory system disease Cardiovascular disease Cardiovascular disease Headaches Headaches Severe dental disease Severe dental disease Needle marks and abscesses - intravenous only Needle marks and abscesses - intravenous only Seizures Seizures

132 Long-term effects of stimulants Strokes, seizures, and headaches Irritability, restlessness Depression, anxiety, irritability, anger Memory loss, confusion, attention problems Insomnia Paranoia, auditory hallucinations, panic reactions Suicidal ideation Sinus infection Loss of sense of smell, nosebleeds, chronic runny nose, hoarseness Dry mouth, burned lips Worn teeth (due to grinding during intoxication) Problems swallowing Chest pain, cough, respiratory failure Disturbances in heart rhythm and heart attack Gastrointestinal complications (abdominal pain and nausea) Loss of libido Malnourishment, weight loss, anorexia Weakness, fatigue Tremors Sweating Oily skin, complexion

133

134

135 Meth Mouth Meth use leads to severe tooth decay Source: The New York Times, June 11, 2005

136 Prenatal meth exposure Preliminary findings on infants exposed prenatally to methamphetamine (MA) and nonexposed infants suggest… Prenatal exposure to MA is associated with an increase in SGA (small for gestational size). Prenatal exposure to MA is associated with an increase in SGA (small for gestational size). Neurobehavioural deficits at birth were identified in NNNS (Neonatal Intensive Care Unit Network Neurobehavioral Scale) neurobehaviour, including dose response relationships and acoustical analysis of the infants cry. Neurobehavioural deficits at birth were identified in NNNS (Neonatal Intensive Care Unit Network Neurobehavioral Scale) neurobehaviour, including dose response relationships and acoustical analysis of the infants cry. (Source: Lester et al., 2005)

137 Chronic stimulant effects Psychological Severe anxiety Severe anxiety Paranoia Paranoia Psychosis Psychosis Irritability Irritability Confusion Confusion Desire to isolate Desire to isolate Memory impairment Memory impairment Inability to concentrate Inability to concentrate Loss of control Loss of control Aggressiveness Aggressiveness

138 Methamphetamine: Psychiatric consequences Paranoid reactions Paranoid reactions Protracted memory impairment Protracted memory impairment Depressive/dysthymic reactions Depressive/dysthymic reactions Hallucinations Hallucinations Psychotic reactions Psychotic reactions Panic disorders Panic disorders Rapid addiction Rapid addiction

139 Stimulant withdrawal symptoms Depression Depression Difficulty concentrating Difficulty concentrating Increased need for sleep / insomnia Increased need for sleep / insomnia Memory dysfunction Memory dysfunction Anxiety Anxiety Decreased sex drive Decreased sex drive Low energy Low energy Irritability Irritability Headache Headache Craving Craving

140 Synaptic activity

141 Meth / Amphetamine Effects: Onset and Duration 1 min3min60 min6 hours 1 min3min20 min30 min Effect Intensity Amphetamine Cocaine Injection Intranasal Swallowed Duration of effect

142 MildModerateToxic Sleeplessness Reduced appetite Dry mouth Crash Suspicion Headache Teeth grinding Anxiety Extreme agitation Incoherence Increased temperature Dehydration Thought disorder Violent aggression Stroke Heart attack Feel good Alert Energy Confidence Feel great Increased libido Increased stamina No need for sleep Amphetamine Effects

143 Typical Pattern of Use (Pead, et al., 1996, p. 37) Low High Symptom Severity UsingStopping Run Intoxication Thought disorder Agitation Insomnia Suspicion Increased energy Feel good Exhaustion Depression Oversleeping Overeating No craving Anhedonia Lack energy Anxiety Sleepless High craving Flat mood Emotionally fragile Episodic craving to cues Days Crash Run Withdrawal

144 Assessment points Occupation Occupation Age Age Social activities Social activities Alcohol and drug (AOD) use history Alcohol and drug (AOD) use history patterns of use, drug type, route, other drug use patterns of use, drug type, route, other drug use Physical health (e.g., stability of weight) Physical health (e.g., stability of weight) Mental health (emotional lability, psychosis/paranoia) Mental health (emotional lability, psychosis/paranoia) Current level of intoxication / evidence of withdrawal Current level of intoxication / evidence of withdrawal Laboratory investigations Laboratory investigations

145 Management of toxic reactions Priorities are: maintain airway, circulation, breathing maintain airway, circulation, breathing control elevated body temperature (hydration, cold water, ice) control elevated body temperature (hydration, cold water, ice) control seizures (IV diazepam) control seizures (IV diazepam) manage psychotic symptoms (antipsychotics) manage psychotic symptoms (antipsychotics) reassurance, support, comfort, minimal stimulation reassurance, support, comfort, minimal stimulation Treatment depends on patients condition on presentation.

146 Activity: Case study Rory, a 24-year-old student, presents with persistent headache, lethargy, and unexplained weight loss. He is burning the candle at both ends, working in a bar and studying, and states that life is pretty hectic at present. Speed helps him get things done. Describe a brief intervention for Rory.

147 Psychostimulant Withdrawal From Pead et al. (1996, p. 84)

148 Withdrawal treatment Immediate withdrawal treatment setting (outpatient or inpatient) setting (outpatient or inpatient) supportive environment, information, and reassurance supportive environment, information, and reassurance provide ongoing monitoring provide ongoing monitoring plan long-term management strategies plan long-term management strategies Planning for prolonged withdrawal anticipate it will be prolonged (i.e., affecting sleep, mood, cravings) anticipate it will be prolonged (i.e., affecting sleep, mood, cravings) plan for lapse and relapse plan for lapse and relapse

149 Pharmacotherapies for psychostimulant withdrawal Aim to decrease discomfort Aim to decrease discomfort Benzodiazepines Benzodiazepines assist sleep or reduce anxiety and agitation assist sleep or reduce anxiety and agitation avoid long-term prescribing avoid long-term prescribing Antipsychotics and Antidepressants Antipsychotics and Antidepressants available research shows limited efficacy available research shows limited efficacy

150 Promising pharmacotherapies? Newton, T. et al (Biological Psychiatry, Dec, 2005) Bupropion reduces craving and reinforcing effects of methamphetamine in a laboratory self- administration study. Newton, T. et al (Biological Psychiatry, Dec, 2005) Bupropion reduces craving and reinforcing effects of methamphetamine in a laboratory self- administration study. Elkashef, A. et al (Neuropsychopharmcology, 2007) Bupropion reduces meth use in an outpatient trial, with particularly strong effect with less severe users. Elkashef, A. et al (Neuropsychopharmcology, 2007) Bupropion reduces meth use in an outpatient trial, with particularly strong effect with less severe users. Tiihonen, J. et al (recently completed; reported at the ACNP methamphetamine satelite meeting in Kona, Hawaii) Methylphenidate SR (sustained release) has shown promise in a recent Finnish study with very heavy amphetamine injectors. Tiihonen, J. et al (recently completed; reported at the ACNP methamphetamine satelite meeting in Kona, Hawaii) Methylphenidate SR (sustained release) has shown promise in a recent Finnish study with very heavy amphetamine injectors.

151 Low threshold treatment services for MSM methamphetamine users Street outreach and field workers in clubs and bath houses Street outreach and field workers in clubs and bath houses Needle exchange Needle exchange Drop-in centres for food, medical services Drop-in centres for food, medical services Housing for homeless methamphetamine users Housing for homeless methamphetamine users HIV risk reduction groups employing peer and professional counselling HIV risk reduction groups employing peer and professional counselling No empirical evidence at this point No empirical evidence at this point

152 Activity: Case study Kylie, a 33-year-old lawyer, recently discovered she was pregnant. She has an active work and social life, and consequently, tends to eat poorly. The pregnancy was unplanned. She is concerned about the health of her baby and her lifestyle that precludes regular eating habits. How would you incorporate an AOD history into your consultation? What triggers may lead you to suspect psychostimulant use?

153 Cocaine Alkaloid from plant leaf of Erythroxylon coca Alkaloid from plant leaf of Erythroxylon coca Known as coke, charlie, snow, okey doke Known as coke, charlie, snow, okey doke Sold in lines Sold in lines Central nervous system stimulant with local anaesthetic actions Central nervous system stimulant with local anaesthetic actions Also stimulates the sympathetic nervous system Also stimulates the sympathetic nervous system Blocks reuptake of dopamine, noradrenaline, and serotonin Blocks reuptake of dopamine, noradrenaline, and serotonin CocaineCrack Crack in vials

154 Cocaine: Metabolism Rapid onset of action (2–8 minutes respectively) Rapid onset of action (2–8 minutes respectively) Peak blood levels occur in 5–30 minutes Peak blood levels occur in 5–30 minutes Action is brief: Action is brief: half-life of 15–30 minutes if injected half-life of 15–30 minutes if injected half-life of up to 30 minutes if snorted half-life of up to 30 minutes if snorted Metabolised by liver, 1%–2% excreted unchanged in urine Metabolised by liver, 1%–2% excreted unchanged in urine Inactive metabolites can be detected in: Inactive metabolites can be detected in: blood or urine for 24–36 hours after use blood or urine for 24–36 hours after use hair for weeks to months after use hair for weeks to months after use

155 Cocaine: Acute and chronic effects Very similar to those associated with methamphetamine. Since the half-life of cocaine is much shorter, in comparison to methamphetamine there is: Somewhat less severe neurotoxicity Somewhat less severe neurotoxicity Somewhat lower frequency of drug- induced psychosis Somewhat lower frequency of drug- induced psychosis Somewhat shorter protracted withdrawal symptoms Somewhat shorter protracted withdrawal symptoms

156 Cocaine: Symptoms of withdrawal Dysphoria (rather than depression), which may persist (up to 10 weeks). Plus at least two of: Dysphoria (rather than depression), which may persist (up to 10 weeks). Plus at least two of: fatigue fatigue insomnia / hypersomnia insomnia / hypersomnia psychomotor agitation psychomotor agitation craving craving increased appetite increased appetite vivid unpleasant dreams vivid unpleasant dreams Withdrawal tends to peak 2–4 days following cessation of use. Withdrawal tends to peak 2–4 days following cessation of use.

157 Cocaine pharmacotherapy Disulfiram has been shown to reduce cocaine use significantly in non-alcohol using cocaine- dependent individuals. However, further research is needed. Disulfiram has been shown to reduce cocaine use significantly in non-alcohol using cocaine- dependent individuals. However, further research is needed. There is substantial use of other medications for treating short- and long-term effects of cocaine use. However, controlled research shows no evidence to support use of these medications. There is substantial use of other medications for treating short- and long-term effects of cocaine use. However, controlled research shows no evidence to support use of these medications.

158 Cocaine: Withdrawal management Non-stimulating / non-threatening environment Non-stimulating / non-threatening environment Possible suicide precautions Possible suicide precautions To date, no effective pharmacotherapies for withdrawal management To date, no effective pharmacotherapies for withdrawal management Prescribed medications: Prescribed medications: Short-term use of benzodiazepines (anxiety, agitation, promote sleep) Short-term use of benzodiazepines (anxiety, agitation, promote sleep)

159 Psychostimulant interventions Be non-judgemental, do not insist on abstinence Be non-judgemental, do not insist on abstinence Engage and retain patient in treatment Engage and retain patient in treatment Understand patients treatment goals Understand patients treatment goals Tailor intervention to suit patient, including level and intensity of referrals Tailor intervention to suit patient, including level and intensity of referrals Offer flexible service delivery, consistent with a patients changing goals and needs Offer flexible service delivery, consistent with a patients changing goals and needs Provide psychosocial support Provide psychosocial support Address concurrent mental health needs, e.g., anxiety, bipolar, or attention deficit disorders are common with cocaine use. Address concurrent mental health needs, e.g., anxiety, bipolar, or attention deficit disorders are common with cocaine use.

160 Treatments for stimulant-use disorders with empirical support Cognitive-Behavioral Therapy (CBT) Cognitive-Behavioral Therapy (CBT) Community Reinforcement Approach Community Reinforcement Approach Contingency Management Contingency Management 12-Step Facilitation 12-Step Facilitation Brief Cognitive Behavioral Therapy Brief Cognitive Behavioral Therapy Matrix Model Matrix Model All have demonstrated efficacy for the treatment of cocaine and / or methamphetamine dependence.

161 Volatile Substances CRACK

162 Volatile substances Commonly referred to as inhalants, solvents, solvent based products Commonly referred to as inhalants, solvents, solvent based products Common terms include chroming, huffing, sniffing, bagging Common terms include chroming, huffing, sniffing, bagging Comprise a group of chemical compounds that change from a liquid or semi-solid to gaseous state when exposed to air Comprise a group of chemical compounds that change from a liquid or semi-solid to gaseous state when exposed to air Inhalation of the vapour through the mouth or nose produces a psychoactive effect (intoxication and euphoria). Inhalation of the vapour through the mouth or nose produces a psychoactive effect (intoxication and euphoria).

163 What substances are used? Inhalants are found in hundreds of products at supermarkets, newsagencies, hardware stores, and industrial sites Inhalants are found in hundreds of products at supermarkets, newsagencies, hardware stores, and industrial sites 4 categories of inhalants: 4 categories of inhalants: Solvents Solvents Aerosols Aerosols Gases Gases Nitrites Nitrites

164 Pharmacology High lipid solubility promotes rapid absorption from the lungs High lipid solubility promotes rapid absorption from the lungs Acute intoxication occurs after 3–5 minutes (10–15 breaths are sufficient) Acute intoxication occurs after 3–5 minutes (10–15 breaths are sufficient) Peak plasma concentration reached in 15–30 minutes Peak plasma concentration reached in 15–30 minutes Half-life varies from hours to days Half-life varies from hours to days Metabolised in kidneys and liver Metabolised in kidneys and liver Accumulate in lipid rich organs (i.e., liver, brain) Accumulate in lipid rich organs (i.e., liver, brain) Crosses placental barrier Crosses placental barrier

165 Highest prevalence among 14- to 17-year-olds

166 Appeal of volatile substances Inexpensive Inexpensive Readily available despite legislation precluding sale to minors Readily available despite legislation precluding sale to minors Can be packaged in small, discrete containers Can be packaged in small, discrete containers Create both rapid intoxication and rapid resolution of intoxication (can use and still return home sober) Create both rapid intoxication and rapid resolution of intoxication (can use and still return home sober)

167 Who uses inhalants? Lack of good epidemiological data, however data from Australia indicates: highest prevalence among 14- to 17-year-olds (c.f., older adults) highest prevalence among 14- to 17-year-olds (c.f., older adults) a small percentage try, but most cease use after a few attempts a small percentage try, but most cease use after a few attempts primarily a short-term, experimental activity by young males (however, female use is increasing) primarily a short-term, experimental activity by young males (however, female use is increasing) recreational users tend to combine solvents and cannabis with ecstasy, speed, or LSD recreational users tend to combine solvents and cannabis with ecstasy, speed, or LSD not restricted to Indigenous communities, but Indigenous youth (compared with non-Indigenous) tend to: not restricted to Indigenous communities, but Indigenous youth (compared with non-Indigenous) tend to: show greater habitual use show greater habitual use use more frequently use more frequently use over a longer period use over a longer period use of solvents is of international concern use of solvents is of international concern

168 Why do youth use volatile substances? Because its fun and exciting Because its fun and exciting I like the way it makes me feel – I feel drunk I like the way it makes me feel – I feel drunk It takes away my bad feelings It takes away my bad feelings I wanted to be part of the gang I wanted to be part of the gang My brothers were doing it so I wanted to try it My brothers were doing it so I wanted to try it Because I want to do something my parents dont like Because I want to do something my parents dont like Because its easy to get and Im not allowed to get alcohol Because its easy to get and Im not allowed to get alcohol ADAC (2000, p. 8)

169 Patterns and methods of use 3 major patterns of use: experimental / occasional experimental / occasional social social long-term dependent / chronic long-term dependent / chronic Methods of use: sniffing sniffing huffing huffing bagging bagging

170 Cues for detecting recent use Red, watery eyes Red, watery eyes Sneezing & coughing (URTI-like symptoms) Sneezing & coughing (URTI-like symptoms) Chemical smell or odour on breath Chemical smell or odour on breath Glue, solvent, or paint stains on clothing, fingers, nose, or mouth Glue, solvent, or paint stains on clothing, fingers, nose, or mouth Apparent intoxication / altered behaviour / risk taking Apparent intoxication / altered behaviour / risk taking Incoherence, confusion Incoherence, confusion Poor coordination Poor coordination Excessive sweating Excessive sweating Unusual spots, marks, rashes and sores around nose and mouth Unusual spots, marks, rashes and sores around nose and mouth Excessive nasal secretions, constantly sniffing Excessive nasal secretions, constantly sniffing

171 Volatile effects – short term Desired effects Euphoria Euphoria Excitation Excitation Exhilaration Exhilaration Sense of invulnerability Sense of invulnerability Disinhibition Disinhibition Negative acute/ short- term effects Drowsiness Drowsiness Flu-like symptoms Flu-like symptoms Nausea and vomiting Nausea and vomiting Headaches Headaches Diarrhoea, abdominal pain Diarrhoea, abdominal pain Unpleasant breath Unpleasant breath Nosebleeds and sores Nosebleeds and sores Reckless behaviour Reckless behaviour

172 Volatile effects – high doses Effects at high doses Slurred speech Slurred speech Poor coordination Poor coordination Disorientation, confusion Disorientation, confusion Tremor Tremor Headaches Headaches Delusions Delusions Visual distortions or hallucinations Visual distortions or hallucinations Unpredictable behaviour, then: Unpredictable behaviour, then: ataxia ataxia stupor stupor final stages (seizures, coma cardiopulmonary arrest, death) final stages (seizures, coma cardiopulmonary arrest, death)

173 Volatiles - overdoses High Doses put user at risk for: Convulsions, seizures, coma Convulsions, seizures, coma Respiratory depression Respiratory depression Cardiac arrhythmias Cardiac arrhythmias Injury or death can occur from: Risk-taking behavior (drowning, falls, etc.) Risk-taking behavior (drowning, falls, etc.) Suffocation Suffocation Aspiration of vomit Aspiration of vomit Burns, explosions Burns, explosions Poisoning, organ failure (chronic use) Poisoning, organ failure (chronic use) Laryngeal spasm (Butane), respiratory arrest Laryngeal spasm (Butane), respiratory arrest Lead poisoning (gasoline / petrol) Lead poisoning (gasoline / petrol)

174 Tolerance and dependence Tolerance develops rapidly with regular use Tolerance develops rapidly with regular use Psychological and physical dependence, while rare, may also occur Psychological and physical dependence, while rare, may also occur

175 Withdrawal Onset and duration Onset and duration not classified in DSM IV but features of possible withdrawal syndrome may commence hours after cessation of use not classified in DSM IV but features of possible withdrawal syndrome may commence hours after cessation of use Withdrawal Symptoms Withdrawal Symptoms sleep disturbances sleep disturbances tremor tremor irritability and depression irritability and depression nausea nausea diaphoresis diaphoresis fleeting illusions fleeting illusions Treatment Treatment symptomatic symptomatic

176 Problems with long-term use Patients may present with a variety of symptoms as a consequence of long-term use, including: chronic headache chronic headache sinusitis, nosebleeds, increased nasal secretions sinusitis, nosebleeds, increased nasal secretions diminished cognitive function diminished cognitive function ataxia ataxia chronic coughing chronic coughing chest pain or angina chest pain or angina tinnitus tinnitus extreme tiredness, weakness, dizziness extreme tiredness, weakness, dizziness depression / anxiety depression / anxiety shortness of breath shortness of breath indigestion indigestion stomach ulcers stomach ulcers

177 Complications from long-term use CNS complications acute encephalopathy acute encephalopathy chronic neurological deficits chronic neurological deficits memory, thinking memory, thinking hearing loss, and loss of sense of smell hearing loss, and loss of sense of smell nystagmus nystagmus motor impairment, especially secondary to lead poisoning motor impairment, especially secondary to lead poisoning peripheral nerve damage peripheral nerve damage Other systems Other systems Renal – nephrolithiasis, glomerulopathies Renal – nephrolithiasis, glomerulopathies Hepatic – reversible hepatotoxicity Hepatic – reversible hepatotoxicity Pulmonary – e.g., pulmonary hypertension, acute respiratory distress Pulmonary – e.g., pulmonary hypertension, acute respiratory distress Cardiovascular – e.g., VF, arrhythmias, acute cardiomyopathy Cardiovascular – e.g., VF, arrhythmias, acute cardiomyopathy Haematological – e.g., blood dyscrasias Haematological – e.g., blood dyscrasias

178 Impact Use of volatile substances (as with use of other psychoactive drugs) impacts not only personal health but also: families families workplace safety workplace safety community (e.g., anti-social behaviour) community (e.g., anti-social behaviour)

179 Responding to intoxication Ensure fresh air Ensure fresh air Be calm, and calming Be calm, and calming Dont chase, argue, use force Dont chase, argue, use force Persuade to cease sniffing (if able to understand) Persuade to cease sniffing (if able to understand) Take person to a safe environment Take person to a safe environment Dont attempt to counsel while intoxicated Dont attempt to counsel while intoxicated Follow-up with parents Follow-up with parents If drowsy or heavily intoxicated If drowsy or heavily intoxicated consider the best environment for the individual and monitor physical and mental health consider the best environment for the individual and monitor physical and mental health

180 Interventions Brief intervention Brief intervention Harm reduction Harm reduction Counselling Counselling Group counselling Group counselling Family support and counselling Family support and counselling Be involved in developing community responses (e.g., Drug Action Teams) Be involved in developing community responses (e.g., Drug Action Teams) Avoid lectures to school / youth groups – evidence suggests it may increase curiosity and level of use.

181 Cannabanoids Hashish Marijuana

182 Cannabis The most widely used illicit drug The most widely used illicit drug The drug most likely to be seen in general medical practise The drug most likely to be seen in general medical practise Generally an experimental or recreational drug, but the most common illicit drug of dependence Generally an experimental or recreational drug, but the most common illicit drug of dependence Use is common among polydrug users Use is common among polydrug users 70% of all drug-related offences relate to cannabis 70% of all drug-related offences relate to cannabis THC or delta­9­tetrahydrocannabinol is the active ingredient of cannabis

183 Case study Mark is a 23-year-old unemployed labourer who presents ostensibly with fatigue. On examination, some psychotic symptoms are apparent. Upon questioning, he says he has been smoking 30 cones of cannabis a day. He is restless, with significant mood swings, racing thoughts and paranoia but no real features of lasting psychosis. Is his presentation consistent with his drug use? How long are his symptoms likely to last? What advice might you give him regarding future use?

184 Cannabis: Forms DEFG A BC

185 Cannabis: Properties Frequently, but erroneously, classified as a narcotic, sedative, or hallucinogen. Sits alone within a unique class. Frequently, but erroneously, classified as a narcotic, sedative, or hallucinogen. Sits alone within a unique class. Degree of effects determined by the THC concentration of specific cannabis material used. Degree of effects determined by the THC concentration of specific cannabis material used. Major active constituent is THC Major active constituent is THC(delta-9-tetrahydrocannabinol). rapidly absorbed and metabolised when smoked, less so when ingested (1–3 hours for psychoactive effects). rapidly absorbed and metabolised when smoked, less so when ingested (1–3 hours for psychoactive effects). Attaches to specific cannabinoid receptors (endogenous brain molecule – anandamide). Attaches to specific cannabinoid receptors (endogenous brain molecule – anandamide).

186 Cannabis: Brain receptors Two types of cannabinoid receptors Two types of cannabinoid receptors CB 1 & CB 2 CB 1 receptors in brain (cortex, hippocampus, basal ganglia, amygdala) and peripheral tissues (testes, endothelial cells) CB 1 receptors in brain (cortex, hippocampus, basal ganglia, amygdala) and peripheral tissues (testes, endothelial cells) CB 2 receptors associated with the immune system CB 2 receptors associated with the immune system Most cannabis effects are via THC acting on CB 1 receptors, which facilitate activity in mesolimbic dopamine neurones Most cannabis effects are via THC acting on CB 1 receptors, which facilitate activity in mesolimbic dopamine neurones

187 Cannabis: Forms & routes Forms include: dried flowers/leaves / buds (marijuana/ganja) dried flowers/leaves / buds (marijuana/ganja) 1% – 24% THC (depending on genetic and environmental factors)1% – 24% THC (depending on genetic and environmental factors) extracted dried resin, sometimes mixed with dried flowers and pressed into a cube (hashish) extracted dried resin, sometimes mixed with dried flowers and pressed into a cube (hashish) around 10% – 20% THCaround 10% – 20% THC extracted oil using an organic solvent (hashish oil) extracted oil using an organic solvent (hashish oil) 15% – 30% THC15% – 30% THC Route of administration can affect dose: smoked (joint, pipe, bong, bucket bong, dose ) smoked (joint, pipe, bong, bucket bong, dose ) 50% absorbed, peak concentration 10 – 30 mins, lasts 2 – 4 hours50% absorbed, peak concentration 10 – 30 mins, lasts 2 – 4 hours ingested (cake, biscuits) ingested (cake, biscuits) 3% – 6% absorbed, peak concentration 2 – 3 hours, lasts up to 8 hours3% – 6% absorbed, peak concentration 2 – 3 hours, lasts up to 8 hours

188 Cannabis: Time to Peak Effect (Smoked)

189 Cannabis: Acute effects Analgesia Analgesia Euphoria, altered concentration, relaxation, sense of calm or wellbeing, disinhibition, confusion Euphoria, altered concentration, relaxation, sense of calm or wellbeing, disinhibition, confusion Increased appetite, thirst Increased appetite, thirst Heightened visual, auditory and olfactory perceptions, inability to appropriately interpret surroundings Heightened visual, auditory and olfactory perceptions, inability to appropriately interpret surroundings Reduced intra-ocular pressure (used for glaucoma treatment) Reduced intra-ocular pressure (used for glaucoma treatment) Nausea, headaches Nausea, headaches With consistent use, URTIs With consistent use, URTIs Problems associated with intoxication Problems associated with intoxication Cannabis overdose does not result in death.

190 Courtesy of Dr. John Sherman, St. Kilda Medical Centre Cannabis

191 Short term, high-dose effects Cannabis also affects: Short-term memory Short-term memory ability to learn and retain new information ability to learn and retain new information task performance task performance balance, stability, mental dexterity balance, stability, mental dexterity the cardiovascular and respiratory systems the cardiovascular and respiratory systems Short-term, high-dose use may result in: synaesthesia synaesthesia pseudo- or true hallucinations pseudo- or true hallucinations delusions, feelings of depersonalisation delusions, feelings of depersonalisation paranoia, agitation, panicky feelings, psychosis paranoia, agitation, panicky feelings, psychosis

192 Long-term effects CNS CNS Respiratory system Respiratory system Cardiovascular system Cardiovascular system Immune system Immune system Endocrine and reproductive systems Endocrine and reproductive systems Adverse social outcomes Adverse social outcomes Mental health problems Mental health problems Cognitive impairment Cognitive impairment Dependence Dependence

193 Cannabis and psychosis THC may exacerbate symptoms of schizophrenia through increase in dopamine release THC may exacerbate symptoms of schizophrenia through increase in dopamine release THC likely precipitates schizophrenia in those vulnerable, i.e., those with a personal or family history of schizophrenia THC likely precipitates schizophrenia in those vulnerable, i.e., those with a personal or family history of schizophrenia Some reports of onset of cannabis- associated schizophrenia in individuals without family risk factors Some reports of onset of cannabis- associated schizophrenia in individuals without family risk factors

194 Cannabis dependence The cannabis dependence syndrome, while now clearly described, is perceived as less pronounced than for other drugs (i.e., opioids, alcohol) The cannabis dependence syndrome, while now clearly described, is perceived as less pronounced than for other drugs (i.e., opioids, alcohol) Not yet listed in DSM IV Not yet listed in DSM IV Variation in frequency, duration of use and dose result in difficulty predicting rapidity, development, and duration of withdrawal Variation in frequency, duration of use and dose result in difficulty predicting rapidity, development, and duration of withdrawal

195 Withdrawal symptoms Anxiety, restlessness, irritability, agitation Anxiety, restlessness, irritability, agitation Racing thoughts Racing thoughts Mood swings and increased aggression Mood swings and increased aggression Feelings of unreality Feelings of unreality Fear, sometimes paranoia Fear, sometimes paranoia Anorexia, stomach pain Anorexia, stomach pain Weight loss Weight loss Increased body temperature Increased body temperature Nausea and salivation Nausea and salivation Drowsiness, through disturbed sleep, and an increase in vivid dreams Drowsiness, through disturbed sleep, and an increase in vivid dreams

196 Assessment Assessment should focus on: drug type, history, route, pattern of use, expenditure drug type, history, route, pattern of use, expenditure tolerance, dependence, potential for withdrawal tolerance, dependence, potential for withdrawal history or evidence of psychiatric sequelae history or evidence of psychiatric sequelae health complications of cannabis use health complications of cannabis use psychosocial context of use (time spent using, obtaining drug, social impact, etc.) psychosocial context of use (time spent using, obtaining drug, social impact, etc.) previous attempts to cut down or quit previous attempts to cut down or quit Assessment tools: SDS SDS ASSIST ASSIST

197 Treatment approaches (1) Brief Advice Provide information on the harms associated with: Provide information on the harms associated with: intoxication intoxication long-term, regular use of cannabis long-term, regular use of cannabis Provide advice on reducing or ceasing use: Provide advice on reducing or ceasing use: Delay, Distract, Avoid, Escape, and dealing with Lapses Delay, Distract, Avoid, Escape, and dealing with Lapses Adopt brief motivational and cognitive-behavioural techniques to manage withdrawal and craving Adopt brief motivational and cognitive-behavioural techniques to manage withdrawal and craving Other strategies may include: Other strategies may include: exercise, stress management, relaxation, hobbies, diet, friends. exercise, stress management, relaxation, hobbies, diet, friends. Early intervention may be more effective than education.

198 Treatment approaches (2) Treatment approaches (2) No specific pharmacotherapies are available yet for managing cannabis withdrawal or relapse.

199 Treatment approaches (3) Treatment approaches (3) Relapse prevention can be achieved through: Relapse prevention can be achieved through: supportive treatment supportive treatment regular follow-up regular follow-up encouraging patient to follow-up treatment with counselling or support groups encouraging patient to follow-up treatment with counselling or support groups use of self-help tools and techniques use of self-help tools and techniques Harm reduction can be promoted by: Harm reduction can be promoted by: assisting patients to identify harms and possible solutions assisting patients to identify harms and possible solutions discussing risks associated with driving or work discussing risks associated with driving or work discussing possible psychosis with those predisposed to such discussing possible psychosis with those predisposed to such

200 Withdrawal management No specific pharmacotherapies for managing cannabis withdrawal or relapse No specific pharmacotherapies for managing cannabis withdrawal or relapse Effectively managed as an outpatient, however severe dependence may require specialised assistance Effectively managed as an outpatient, however severe dependence may require specialised assistance engage in brief interventions, including relapse prevention and problem solving skills engage in brief interventions, including relapse prevention and problem solving skills consider shared care with psychologists and / or experienced AOD workers consider shared care with psychologists and / or experienced AOD workers

201 Pharmacology for withdrawal Medications may be useful for a limited time: sedative / hypnotics sedative / hypnotics e.g., diazepam 5 – 10 mg qid prn, temazepam, 10 – 20 mg nocte for a few days antipsychotics (for severe agitation or psychosis) antipsychotics (for severe agitation or psychosis) e.g., haloperidol or novel agents

202 Questions?Comments? ? ? ?

203 Post-assessment Please respond to the post-assessment questions in your workbook. (Your responses are strictly confidential.) 10 Min.

204 Thank you for your time! End of Workshop 3 END OF MODULE 1


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