Dealing with Alcohol and Drug use

Transcription

1 Dealing with Alcohol and Drug use Role of Social Workers / Psychologists Role clarity Helpful Listening well Commitment Patience T T Ranganthan Clinical Research Foundation TTK Hospital, IV Main Road, Indira Nagar, Chennai Ph : / ttrcrf@gmail.com, ttkhospital@gmail.com

2 2 Dealing with Alcohol and Drug use Role of Social Workers / Psychologists Alcohol and drug use related problems can be identified in all socio economic groups. By virtue of their professional work, social workers/ psychologists are in a position to identify problem alcohol/drug users and intervene meaningfully. To help social workers/ psychologists carry out this task well, this booklet will provide basic information about: alcohol and other drugs signs and symptoms related to substance dependence (addiction) a frame work for screening and brief intervention carrying out referral for addiction treatment Alcohol and other psychoactive drugs that can lead to addiction are collectively referred to as substances. Substances can be legal (like alcohol) or illegal (like cannabis and heroin). Medically used drugs such as pain killers and sleeping tablets can also lead to addiction when used without the doctor s advice or in a larger quantity or frequency than prescribed. Substances most commonly used in India: Alcohol and cannabis are most commonly abused substances. Opiate drugs such as heroin (brown sugar), buprenorphine, codeine based cough syrups and spasmoproxyvon Sleep inducing drugs which are medically used drugs Volatile solvents such as adhesives, eraser fluids etc. Stimulants such as ecstasy and other amphetamine type substances Substance use disorders can be discussed under two heads: i. Substance Abuse: The user is not addicted to substances and does not meet the diagnostic criteria for substance dependence. But, the user may repeatedly face family, work or legal problems due to substance use or may put himself or others at risk due to it (eg: driving) and yet continue to use in spite of the social or interpersonal problems. ii. Substance dependence: Addiction to substances is referred to as substance dependence. DSMIVTR (Diagnostic and Statistical Manual of Mental Disorders IV Text Revision) lists diagnostic criteria for substance dependence. 2

3 3 The DSMIVTR lists seven criteria to assess substance use and if three or more are noted in the past 12 month period, diagnosis of substance dependence (addiction) can be made. Counselors can look for the seven criteria listed below based on the information collected from the patient. Each of the criteria has been presented with an example in brackets to build understanding. However, diagnosis of substance dependence must be made by a person qualified to do so. 1. Tolerance: The person is unable to experience the same intensity of effect with the usual quantity and starts increasing the quantity of drugs used. (While previously one tablet produced the sought after effect, gradually two tablets or more are needed to experience the same effect). 2. Withdrawals: The person experiences discomfort if drug use is discontinued. (Tremors, irritability, sleeplessness or hallucinations may set in if alcohol use is discontinued) 3. The person uses a larger amount of the drug or for a longer period than he initially planned to. (The person may decide to drink a smaller quantity of alcohol and get back home earlier but ends up drinking the usual quantity and spending as much time as he did earlier) 4. The person persistently wishes to or repeatedly makes efforts to reduce / stop using drugs but is unable to. (Though the person wants to change the pattern of drug use, he finds that he is unable to do so). 5. Spends a lot of time in drug use related activities. (A good part of time is spent in making plans to get the drug, using it or being under the influence of it). 6. The person may give up important social, occupational or recreational activities due to the drug use. (The person may show less interest or involvement in family, work or leisure activities as drug use seems more important). 7. Substance use continues in spite of the person facing problems repeatedly due to it. (The person is affected by one or more problems related to health, work or family and yet unable to give up drug use) 3

4 4 Alcohol: Alcohol acts as a depressant on the central nervous system and slows down the activity of the brain. Small quantity of alcohol lowers inhibitions and produces a sense of relaxation and at times it can also increase hostility or depression. Alcohol slows down reflexes, interferes with judgment and affects coordination and the user is not able to respond quickly and appropriately. Slurred speech, blurred vision, drowsiness are also noted. The risk of falls and accidents increases tremendously when a person uses alcohol. Alcohol use is associated with over 60 types of disease and injury. Though a large part of the population remains abstinent from alcohol in India, those who drink do so at hazardous levels placing themselves as well as others at risk. All alcoholic beverages contain ethyl alcohol though the percentage varies. The amount of ethyl alcohol present is calculated in units. Distilled spirits (brandy, whisky, rum etc) contain 42.8% alcohol and 30 ml of such spirits is referred to as ONE unit. Half of a bottle of beer (325 ml) is also estimated to contain ONE unit of alcohol as beer contains only 56% of ethyl alcohol content. Two out of ten people who use alcohol develop physical and psychological dependence and face problems due to alcohol use. Tremors, sleep problems, irritability, restlessness and anxiety can set in if the person stops alcohol use. Convulsions and hallucinations and Delirium Tremens (DT) are also possible withdrawal symptoms. If the person develops DT, confusion, disorientation, hallucinations and delusions can set in and medical supervision is essential as DT can be life threatening. Cannabis (ganja /charas / bhang): All cannabis drugs come from the same plant and its use has been reported from all parts of the country. Cannabis is usually smoked in the form of handmade cigarettes; while rarely it is added to milk, tea and other eatables. It causes mild euphoria, reduces inhibition and ability to perform complex motor tasks such as driving or operating machinery. Cannabis use can trigger an acute psychotic episode and worsen other mental health problems that the user may have. Cannabis also interferes with comprehension, memory and learning ability. Cannabis use can lead to psychological dependence and the person can become addicted. When cannabis use is discontinued, restlessness, irritability, disturbed sleep with nightmares, loss of appetite and depression can be noted and the person may revert back to cannabis use. 4

5 5 Heroin and other opiates: These are highly addictive pain relieving drugs which also cause some amount of sedation. Heroin (commonly known as brown sugar) is an illegal drug while other opiates such as codeine (present in cough syrups), spasmoproxyvon, buprenorphine etc are pharmaceutical preparations which are prescribed medically. These medically used drugs are safe and useful when used as advised by the physician. However, when a person uses drugs without the doctor s advice or for the pleasure associated with the drug, addiction develops. When the addicted person attempts to reduce or stop using the drugs, body pain, restlessness, vomiting, alternating sweating and body chills as well as severe craving for the drug is experienced. While withdrawal from these drugs is not life threatening and will subside in about 7 to 10 days, withdrawal symptoms make it difficult for the user to stop using the drug. The psychological craving for the drug can persist even after the physical withdrawal symptoms clear up. Sleep inducing drugs: Drugs such as diazepam help induce sleep and reduce anxiety. Many misuse these drugs prescribed by the doctor and gradually get addicted. Heavy alcohol users often use these drugs in addition to alcohol which places them at risk of over dose deaths. Heroin and other opiate users may sometimes use these drugs to enhance the effect. If dependence develops the person may feel agitated, anxious and have sleep problems if drug use is discontinued. Inhalant drugs: Glue, whitener, petrol etc., are sniffed mostly by children and adolescents for the short lived euphoria they produce. However, associated risks are very high. Inhalants can cloud thinking, make them disoriented, cause hallucinations, slurred speech and can sometimes lead to death. It can cause brain damage, affect the liver and kidneys, interfere with heart rhythm and can trigger acute psychosis. Head aches, sinusitis and nose bleeds are common. When inhalant use is discontinued mild withdrawals such as anxiety, tremors and nausea may appear. Stimulants: Amphetamine type substances such as ecstasy, heighten sense of well being and increase energy levels and motor activity. The person is able to continue to work or dance without fatigue for long periods of time. Physical deterioration due to poor appetite and sleep problems, risk of violence and suicide and drug related psychosis are some of the risks involved. When a person attempts to stop using the drug after regular use, extreme fatigue and severe depression can set in. 5

6 6 Dangers associated with substance use / abuse Even occasional use of alcohol / drugs can place a person and others at risk especially when driving a vehicle or operating machinery. In India 60% of all injuries in the emergency room were found to be related to alcohol use (World Health Organization, Alcohol control series no.2, 2006). The level of risk associated with substance use is higher among youngsters as their body is still in the process of growing, active brain development is taking place and personality is being shaped. Use of alcohol and other substances can interfere with brain development, cognition and affect intellectual capacity. Risk of assaults, violence and crime can also increase due to poor impulse control and impaired judgment caused by substance use. Risk of overdose deaths due to use of sleeping pills along with alcohol or other opiate drugs is high. Continued use of substances causes general physical deterioration as it reduces appetite, disturbs sleep pattern and leads to poor self care. As taking the drug seems more and more important, health problems are not recognized and lack of medical attention can cause serious problems. Gastritis, neuritis and liver problems are common among heavy alcohol users. The link between cannabis use and psychiatric disorders, respiratory infections and reduction in the level of male sex hormones has been well established. Heroin and other drugs which are injected increase the risk of blood born diseases such as HepatitisB, HepatitisC and HIV when injecting equipment is shared. Injecting drugs can also lead to abscess, ulcers, collapsed veins etc., Mental health problems can be triggered or made worse due to substance use. Depression, mood disorders, paranoia, hallucinations and delusions are commonly reported. The tendency to display antisocial behaviour markedly increases. Permanent brain damage can occur. Long term use of substances can affect memory, concentration and cognitive ability which impact negatively on the learning process. Substance dependence can affect all areas in one s life health, school / work performance, family and social relationships as well as the financial situation. Possession of illegal drugs such as cannabis or heroin is a crime and one is at risk of prosecution and imprisonment. Moreover, it changes the way one perceives and manages the pressures of daily living and generally deteriorates the quality of life. The happy, energetic and enthusiastic youngster can lose interest in achievement and become dull, depressed and physically run down. A person who is a hard working employee, a loving father, and a caring husband can end up as a chronic absentee at work and irritable and withdrawn at home when addiction develops. Addiction is treatable: With proper professional help, the substance dependent can give up the use of alcohol and drugs completely and live a productive and happy life. 6

7 7 Four areas for professional intervention by social workers/psychologists/ counselors: 1. Prevention 2. Early identification based on indirect indicators of substance abuse 3. Screening, intervention and referral 4. Treatment and Rehabilitation Area of intervention 1 Prevention: Prevention programmes can: Dissuade people from trying alcohol / other drugs Help them recognize risks associated with alcohol and alter drinking pattern Build understanding of dangers associated with use of illegal drugs as well as prescription drugs without the doctor s advise Facilitate development of healthy alternatives to alcohol and drug use Motivate them to seek help to handle problems if any For effective prevention: Messages need to be repeatedly presented. Just one or two programmes do not help. Bringing about a shift in attitude towards drug use and behavior takes time. The content and methods used to undertake prevention needs to be tailored according to the group. The type of drug used, the excuses cited and the alternatives suggested vary depending upon the group addressed. Different approaches such as lectures, role plays, poster displays, puppet shows, street plays etc can be used appropriately. Just providing information about alcohol and drugs is not sufficient. When addressing students, teaching them how to say No to drug offers, building decision making skills and helping strengthen self esteem are also important. With adult men, discussing ways to handle celebrations, stress or tiredness after days of hard work without resorting to use of alcohol or drugs is essential. Awareness programmes need to be undertaken for all groups in the community. In schools, programmes should be conducted for parents and teachers as well as students. When prevention is undertaken in work places, programmes should be conducted for all levels of employees workers, supervisors as well as executives. 7

8 8 Area of intervention 2 Early identification based on indirect indicators of substance abuse: Some individuals may seek help to deal with alcohol and drug problems on their own initiative or due to persuasion of their families and friends. But many fail to recognize the problem and do not seek help in the early stages of problem substance use. Professionals who are familiar with alcohol / drug use related issues can help identify addiction in the early stages and persuade them to seek help. It is important to remember that the earlier the intervention, the harm caused due to substance use would be less and the outcome of intervention would be better. Given below is the list of hidden indicators. These indicators cannot be taken as proof of substance use related problems, but can alert one to the possibility and the need to intervene effectively. a. Work place indicators: Absenteeism Poor quality and quantity of work output Involvement in accidents Frequent demand for loans Poor interpersonal relationships Poor grooming (unshaven, not being well dressed etc.) b. Health care settings indicators: Gastritis, neuritis and liver disorders are health problems commonly associated with hazardous level of alcohol use. Abscesses or ulcers in injection sites are common among intravenous drug users. Sleep problems, irritability, violence and physical deterioration with no known medical problems Poor compliance with medications and repeated hospital admissions Frequent falls or accidents 8

9 9 c. Indicators based on spouse s behaviour: Socially withdrawn and depressed Suicidal attempts Poor care of self (poor sleep, skipping meals, delay in accessing medical help etc) Bruises(due to domestic violence) Standard of living not in keeping with the income level d. Indicators based on child s problems The stressful dysfunctional family can affect the children and they may Lack concentration Appear dull and withdrawn Have problems in getting along with others Display behaviour problems like hyperactivity, rebelliousness and aggression Perform poorly in their studies in spite of adequate IQ levels Be poorly groomed (cleanliness, neatness etc.,) and display other signs of child neglect Area of intervention 3 Screening, intervention and referral: Screening for alcohol and drug related problems can be done on a routine basis in a health care setting. Presence of indirect indicators listed above also warrants screening. Presented below is a step by step process for screening and interventions. Step I. Collect details about quantity and frequency of alcohol and drug use and administer AUDIT or DAST if necessary i. Prescription drug use: If the person is using more than prescribed or continues to renew the prescription without consulting the doctor persuade him to meet the doctor to discuss drug use. Present information about risks involved in using prescription drugs. ii. iii. If use of cannabis, heroin or inhalant use is reported, DAST (Drug use questionnaire) can be used to identify problems related to drug use. (DAST can be downloaded). Discuss risks involved and emphasize need to stop drug use. Provide details of addiction treatment facilities and make a referral. If the individual reports alcohol use, calculate number of units consumed per day and per week. Use of more than three units per day and more than seven units per week indicates a risky drinking pattern. 9

10 10 If the person is drinking less than seven units a week and never drinks more than three units in a typical drinking day, emphasize that No alcohol use is the safest decision. Remind them about risk associated with driving after consuming even small quantities of alcohol. If consumption is more than seven units per week, administer AUDIT. (Remember that 30 ml of whisky / rum = 350 ml of beer = 1 unit of alcohol). Alcohol Use Disorders Identification Test (AUDIT) Ask each question, tick the response and total the scores listed beside the answer 1. How often do you have a drink containing alcohol? Never (0) Monthly or less(1) 4 times a month(2) 23 times a week(3) 4 or more times a week(4) 2. How many drinks containing alcohol (number of units) do you have on a typical day when you are drinking? 1 or 2 (0) 3 or 4(1) 5 or 6(2) 7 or 9 (3) 10 or more (4) 3. How often do you have six or more drinks (number of units) on one occasion? Never (0) Less than monthly(1) Monthly(2) Weekly(3) Daily or almost daily(4) 4.How often during the last year have you found that you were not able to stop drinking once you had started? Never(0) Less than monthly(1) Monthly(2) Weekly(3) Daily or almost daily(4) 5.How often during the last year have you failed to do what was normally expected from you because of drinking? Never (0) Less than monthly(1) Monthly(2) Weekly(3) Daily or almost daily(4) 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never(0) Less than monthly (1) Monthly(2) Weekly (3) Daily or almost daily(4) 7.How often during the last year have you had a feeling of guilt or remorse after drinking? Never (0) Less than monthly (1) Monthly (2) Weekly(3) Daily or almost daily(4) 8.How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never(0) Less than monthly(1) Monthly(2) Weekly(3) Daily or almost daily(4) 9.Have you or someone else been injured as a result of your drinking? No (0) Yes, but not in the last year(2) Yes, during the last year(4) 10

11 11 10.Has a relative or a friend or a doctor or other health worker been concerned about your drinking or suggested that you cut down? No (0) Yes, but not in the last year(2) Yes, during the last year(4) Add scores of the 10 questions to arrive at the AUDIT score Step 2: Present simple advice based on AUDIT score. If DAST scores indicate problems refer for specialized help. AUDIT score 8 15: Explain that present drinking pattern is harmful. Emphasize that No alcohol use is the safest decision. Discuss what can be done to reduce or stop alcohol use. Remind them about risk associated with driving after consuming even small quantities of alcohol. AUDIT score 1619: Explain that drinking pattern is harmful and needs to be addressed immediately. Involve the family if possible. Emphasize that No alcohol use is the safest decision. Remind them about risk associated with driving after consuming even small quantities of alcohol. Persuade individual to seek help to handle drinking. AUDIT score 20 or more: Explain that these scores indicate highest level of risk associated with drinking and refer for help from specialized addiction treatment center. Step 3: Referral: If substance dependence (addiction) has not yet developed, information about dangers associated with substance use must be provided. For further help, referral for specialized addiction services can be made. If substance dependence is present, referral for treatment must be made. Social workers / psychologists need to be familiar with the facilities available in the community and refer them to centers which offer professional services with the essential treatment components. Providing information about the self help groups such as Alcoholics Anonymous (for alcohol dependents) and Narcotics Anonymous (for other drugs) helps. Explaining the philosophy and free help available at these meetings and details related to the time, days and places where the meetings are held in the community is important. 11

12 12 Area of intervention 4 Treatment and Rehabilitation Substance dependence (addiction) is a treatable disease. With the right help, it is possible to stop using alcohol / drugs completely and live meaningfully. However, if substance dependence has developed (once addicted), it is not possible to reduce or restrict the alcohol or drug use. Giving up completely and maintaining abstinence over one s life is the only option. Addiction treatment helps one to achieve and maintain abstinence from all mood changing drugs and also make qualitative changes in one s lifestyle. Four important components of addiction treatment are: Medical help needs to be provided to make the withdrawal process safe and comfortable. Health problems caused or made worse due to substance use and mental health problems need to be treated. Some medications can also help alcohol and opiate users to stay drug free thereby providing additional support during early recovery. Psychological therapy is essential to help the patient recognize the damage caused by substance use, identify areas that need to be changed, develop a plan to handle triggers for substance use and improve quality of life. Addiction affects the family members also. During treatment it becomes important to provide information as well as support to family members to help them recover and also build a supportive family environment for the patient. Follow up services at least for a period of two years is necessary to support continued abstinence from alcohol and drugs. Relapses which may happen need to be addressed as quickly as possible to stabilize recovery. In an addiction treatment center, social workers and psychologists can handle: Input sessions to provide information about substance use, problems related to dependence as well as recovery and relapse prevention Group therapy sessions to build insight into one s issue and resolve them with the help of the group Counselling sessions for the patient to address issues identified in the individualized treatment plan and work with the family too Follow up sessions to provide continued support for recovery 12

13 13 As addiction is a brain disease, the quality of the psychological therapy is crucial for an effective treatment programme and social workers/ psychologists play an important role. TTRCRF popularly known as TTK Hospital is a non profit organization working in the field of addiction management since Operating from a 100 bed capacity unit at Chennai, we offer a range of services that include: One month residential addiction treatment programme that consists of detoxification and psychological therapy which is designed to help patients achieve abstinence from use of alcohol and drugs and establish a quality lifestyle. Two month extended care treatment programme with similar treatment components Two week family therapy programme for family members of alcohol and drug dependents Relapse prevention and intervention programme Out reach community based camps for treatment of alcoholism in the rural areas Prevention and awareness efforts Training on addiction treatment for various groups (doctors, nurses, counselors and others) to build knowledge and skills related to addiction treatment Publications of books and other material about addiction and recovery. TT RANGANATHAN CLINICAL RESEARCH FOUNDATION TTK HOSPITAL IV MAIN ROAD, INDIRA NAGAR, CHENNAI Telephone: / ttrcrf@gmail.com, ttkhospital@gmail.com 13