1. Polydrug Use

2. Polydrug Use Defined Polydrug use refers to: “...the concurrent use of multiple drugs, or the combining of drugs. It can occur in a range of patterns and for a variety of reasons, and may or may not involve drug dependence.” Swan & Ritter (2001, p. 1)

3. Polydrug Use Becomes a concern in terms of its relative risk Generally associated with hazardous or harmful use of > 1 drug Appears to be ‘the norm’ amongst many drug- using groups –many of whom rarely limit use to one drug, or –who use a primary drug along with a range of other drugs Is highly prevalent among clients of drug treatment services.

4. Polydrug Use Patterns of Polydrug Use Think about: context, patterns of use and dependence Common patterns of use include: –using from multiple drug classes, but there is no evidence of dependence on any one class of drug –dependence on one drug class, but use of other drugs –dependence on several drugs or classes of drugs.

5. Polydrug Use The Nature of Polydrug Use Polydrug use depends on a range of factors: –demographic and social – availability and price –desired effect and outcome of use –previous experiences (institutionalisation or previous medical treatment appears to influence polydrug use behaviours).

6. Polydrug Use Reasons for Polydrug Use To enhance effects of other drugs To counteract effects of other drugs To provide a substitute for a preferred but unavailable drug To conform to normative ways of using drugs To counteract the unpleasant effects of drugs from different classes To self-manage the withdrawal from one drug by using another.

7. Polydrug Use Common Drug Interactions (1)

8. Polydrug Use Common Drug Interactions (2)

9. Polydrug Use Harms from Polydrug Use Intoxication, Regular Excessive Use and Dependence Intoxication accidents overdose and poisoning hangovers absenteeism high-risk behaviour Regular Excessive Use health finances relationships work Dependence impaired control, drug centred behaviour severe social or psychological problems, withdrawal I R D

10. Polydrug Use Service Provision and Polydrug Use Engage into treatment Ensure effective collaboration Use Harm Reduction strategies –prevention BBV, reduce use, crisis intervention Multimodal treatment and cross referral Regular review.

11. Polydrug Use Polydrug Assessment Issues (1) Conduct a systematic assessment of each drug class –episodic use, time frame of at least 4 weeks, changing patterns of use with changing availability, dependence (>1 drug?). Include tobacco ! Examine relationship between use of various drugs –Is use of one drug related to the absence or use of another? Any drug free periods? Use of one drug to modify withdrawal from another? Identify drug use patterns, dependence and high-risk using practices –use of drugs from different classes +/- dependence on one or all.

12. Polydrug Use Polydrug Assessment Issues (2) Try to gain a sense of: patient’s reasons for choosing to use particular drugs their multiple problems or concerns how their drug use and lifestyle affects them (include both positive and negative aspects) potential for withdrawal.

13. Polydrug Use Screening WHO is developing a composite polydrug screening instrument: ASSIST: A lcohol, S moking & S ubstance I nvolvement S creening T ool To be used in primary health care settings to help GPs decide whether the patient will benefit most from: –information –brief intervention, or –referral to specialised treatment.

14. Polydrug Use Other Assessment Issues Allow adequate time (more time is needed than for a single drug assessment) Obtain corroborating information –e.g., friends / family, with consent Delay assessment if intoxicated – apply harm reduction principles Consider your role and the practice staff in the management of people with complex polydrug use issues.

15. Polydrug Use Key Issues in Treatment Harm mimimisation strategies a priority Opportunistic brief interventions are often all that can be delivered Long-term treatment perspective is required – few people abandon all drug use in the short term Numbers of drugs used tend to  with age Patients may only be interested in dealing with most immediate/problematic issues.

16. Polydrug Use GPs and Management (1) Polydrug issues are complex, patients often present in crisis. Clarify your role Consider a ‘shared care’ approach: –AOD specialists (including mental health services) –relevant local health and welfare agencies –crisis intervention services –families and other peer support groups (esp. useful with young people).

17. Polydrug Use GPs and Management (2) Develop ongoing therapeutic relationship (BI, counselling etc.); encourage return despite possible frequent non-attendance With patient, identify which (most harmful) drug to tackle first for stabilisation or withdrawal Polydrug withdrawal is complex – work with (or refer to) specialists Ensure contact and liaison with other AOD services.

18. Polydrug Use GPs and Management (2) Develop ongoing therapeutic relationship (BI, counselling etc.); encourage return despite possible frequent non-attendance With patient, identify which (most harmful) drug to tackle first, for stabilisation or withdrawal Polydrug withdrawal is complex – work with (or refer to) specialists Ensure contact and liaison with other AOD services.

19. Polydrug Use Who is Suitable for Counselling? Counselling is suitable for those who: –self-identify as polydrug users –are subject to court orders –are pressured into treatment by employers, family or friends Counselling is not suitable for those who: –are actively psychotic –have significant cognitive impairment or intellectual impairment –are grossly intoxicated.

20. Polydrug Use A Final Comment If the young polydrug user can be kept alive, and free of disease, there is a natural tendency towards eventually moderating or giving up drug use. Treatment may provide ‘a nudge along the natural pathway of recovery’.