Polydrug Use

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. 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. 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. 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. Common Drug Interactions (1)

8. Common Drug Interactions (2)

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

10. 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 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 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. Screening • WHO is developing a composite polydrug screening instrument: ASSIST: Alcohol, Smoking & Substance Involvement Screening Tool • To be used in primary health care settings to help GPs decide whether the patient will benefit most from: • information • brief intervention, or • referral to specialised treatment.

14. 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. 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. 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. 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. 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.

19. 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’.