Fuel to the Fire?Fuel to the Fire?

Drug Users Who DrinkDrug Users Who Drink

Is there a problem?Is there a problem?

1990 – Almost 100% was Alcohol problems1990 – Almost 100% was Alcohol problems

In 1992 3% of our Clients were under 25In 1992 3% of our Clients were under 25No IVDUNo IVDUPrescribed use MinimalPrescribed use Minimal

2002 an equal split between age groups2002 an equal split between age groupsHigh amounts of Heroin useHigh amounts of Heroin useRapid transition to IVDURapid transition to IVDU

2002 we started to notice a link between drug and alcohol use2002 we started to notice a link between drug and alcohol use

Arising AwarenessArising Awareness

At first through observation on street At first through observation on street work and needle exchangework and needle exchange

By requests for AlcometerBy requests for Alcometer

Through alliances between at first Through alliances between at first apparently disparate groupingsapparently disparate groupings

Through networkingThrough networking

LocationsLocations

Other IssuesOther Issues

Interaction with other drugs – Lothian Interaction with other drugs – Lothian OverdosesOverdoses

Issues around HEP CIssues around HEP C

Aggression and ViolenceAggression and Violence

But Why?But Why?

Lets Revisit Lets Revisit

God’s Own MedicineGod’s Own Medicine

Sir William OstlerSir William Ostler

"I'll Die Young, but It's Like"I'll Die Young, but It's LikeKissing God"Kissing God"

The Consumption of Heroin Is Marked by a The Consumption of Heroin Is Marked by a Euphoric Rush, a Warm Feeling of Euphoric Rush, a Warm Feeling of Relaxation, a Sense of Protection, and a Relaxation, a Sense of Protection, and a dissipation of pain, fear, hunger, tension dissipation of pain, fear, hunger, tension and anxiety. and anxiety.

When Heroin Is Snorted or Smoked but When Heroin Is Snorted or Smoked but Especially Injected, the Rush Is Intense Especially Injected, the Rush Is Intense and Orgasmic. Subjectively, Time May and Orgasmic. Subjectively, Time May Slow Down. Anger, Frustration and Slow Down. Anger, Frustration and Aggression Magically Disappear.Aggression Magically Disappear.

We replace withWe replace with

MethadoneMethadone

DF118sDF118s

Enforced ReductionEnforced Reduction

Abstinence AloneAbstinence Alone

Remember …Remember …

Heroin Works..Heroin Works..

QuicklyQuickly

ConsistentlyConsistently

Without workWithout work

EfficientlyEfficiently

Works well with traumaWorks well with trauma

Client CClient C

I hated drugs – hated drug users but I hated drugs – hated drug users but one night I was rattling of the drink one night I was rattling of the drink someone gave me a burn – I felt someone gave me a burn – I felt normal for the first time in my lifenormal for the first time in my life

Other Possible Factors In Rise Of Other Possible Factors In Rise Of Alcohol useAlcohol use

Controlled DispensingControlled Dispensing

Diazepam ceilingsDiazepam ceilings

Fake DiazepamFake Diazepam

Mundanity of methadone LifestyleMundanity of methadone Lifestyle

Social ExclusionSocial Exclusion

The Muirhouse ExperienceThe Muirhouse Experience

Reasons for researchReasons for research

Initiated through NEARInitiated through NEAR

Response to new problemResponse to new problem

Identified as not conventional issuesIdentified as not conventional issues

Of the twenty-five interviewed, 17 (68%) Of the twenty-five interviewed, 17 (68%) were living in Muirhouse, while six (24%) were living in Muirhouse, while six (24%) were from the immediate surrounding were from the immediate surrounding areas (e.g. West Pilton), and two (8%) areas (e.g. West Pilton), and two (8%) were from other parts of Edinburgh were from other parts of Edinburgh although originally from the Muirhouse although originally from the Muirhouse area. Only one (4%) of the group did not area. Only one (4%) of the group did not stay in their own home, while 96% of the stay in their own home, while 96% of the group rented their own council flats. group rented their own council flats. Twenty-one (84%) were registered with a Twenty-one (84%) were registered with a GP in the area. It is important to recognise GP in the area. It is important to recognise that all the Street Drinkers interviewed that all the Street Drinkers interviewed had long connections with the area, and had long connections with the area, and that all had stayed in the area at one time that all had stayed in the area at one time or another for significant periodsor another for significant periods

Frequency of drinking

13%

4%

8%

21%54%

Once every twoweeks or less

Once a week orless

Once/twice a week

More than twice aweek

Every day

ConsumptionConsumption

The average daily units consumed by The average daily units consumed by those that drink at the Muirhouse those that drink at the Muirhouse Shopping Centre were 9.6, although Shopping Centre were 9.6, although this was only based on data from ten this was only based on data from ten people. The majority of the street people. The majority of the street drinkers were unable to estimate drinkers were unable to estimate how much they drank on a typical how much they drank on a typical day, and reported that it was day, and reported that it was dependent on other variables such as dependent on other variables such as availability and mood. availability and mood.

Attitude to DrinkingAttitude to Drinking

When asked how they felt about their When asked how they felt about their drinking patterns, 58% of the group drinking patterns, 58% of the group replied that they were unhappy with replied that they were unhappy with the level of alcohol intake. Of that the level of alcohol intake. Of that 58%, half wished to drink less, and 58%, half wished to drink less, and the remaining half wished to stop the remaining half wished to stop drinking altogetherdrinking altogether

But All very Interesting…But All very Interesting…

DrugsDrugs

The vast majority of those The vast majority of those interviewed were on maintenance interviewed were on maintenance prescriptionsprescriptions

Practically all had at one time used Practically all had at one time used opiates in one form or anotheropiates in one form or another

Routes for helpRoutes for help

0

5

10

1520

25

30

35

40

4550

Friends Family GP NEDAC Police Social Work Community Groups Housing Support Worker

Proposed avenues of assistance

Why Lack of Clarity?Why Lack of Clarity?

Social acceptability of alcoholSocial acceptability of alcohol

Inability to assessInability to assess

Unwillingness to challengeUnwillingness to challenge

Scale of issue compared to HeroinScale of issue compared to Heroin

Alcohol Dependency SyndromeAlcohol Dependency Syndrome

1.1. Narrowing of drinking repertoireNarrowing of drinking repertoire 2.2. Salience of drink seeking activitySalience of drink seeking activity 3.3. Increased toleranceIncreased tolerance 4.4. Repeated withdrawal symptomsRepeated withdrawal symptoms 5.5. Relief drinkingRelief drinking 6. Awareness of compulsion to drink6. Awareness of compulsion to drink 7.7. Rapid reinstatement after Rapid reinstatement after

abstinenceabstinence

For us as drug workers…For us as drug workers…

Alcohol misuse by clients undergoing Alcohol misuse by clients undergoing Methadone Treatment Programmes Methadone Treatment Programmes has been recognised as a factor in ….has been recognised as a factor in ….• Poor treatment outcome Poor treatment outcome • Increased morbidity Increased morbidity • Early termination of treatmentEarly termination of treatment

Methadone/Opiate related deathMethadone/Opiate related death Increased social, family and Increased social, family and

psychiatric disorderpsychiatric disorder

Client JClient J

I found myself at the offy at 7.30 in the I found myself at the offy at 7.30 in the morning ..I would look at the troops morning ..I would look at the troops at the pharmacy waiting for their at the pharmacy waiting for their script and say” Thank god I’m nae script and say” Thank god I’m nae like them no more” ..”I didn’t know it like them no more” ..”I didn’t know it I was worse”I was worse”

Size of the ProblemSize of the Problem

Heavy drinking is widespread among Heavy drinking is widespread among drug users. Heavy drinking can be a drug users. Heavy drinking can be a serious threat to the health of drug serious threat to the health of drug users because of the high rates of users because of the high rates of liver disease among drug injectors liver disease among drug injectors and because of the increased and because of the increased potential for drug overdose when potential for drug overdose when alcohol and drugs are used togetheralcohol and drugs are used together

Size Of The ProblemSize Of The Problem

20.9% of Methadone Maintenance 20.9% of Methadone Maintenance clients have been shown to meet the clients have been shown to meet the criteria for alcohol dependencecriteria for alcohol dependence

Alcohol Consumption – NTORSAlcohol Consumption – NTORSNational Treatment Outcome National Treatment Outcome

Research StudyResearch Study 68% reported drinking alcohol in the 3 68% reported drinking alcohol in the 3

months prior to treatmentmonths prior to treatment 32% had not consumed any alcohol during 32% had not consumed any alcohol during

this periodthis period 27% of clients drank above recommended 27% of clients drank above recommended

limitslimits 14% of the clients drank on a daily basis14% of the clients drank on a daily basis 8% were drinking in the region of 45 units 8% were drinking in the region of 45 units

on a daily basis on a daily basis

Alcohol Consumption - NTORSAlcohol Consumption - NTORS

Among the drinkers, the average Among the drinkers, the average alcohol consumption by men was 50 alcohol consumption by men was 50 units per week (compared to 15.4 units per week (compared to 15.4 units in general population) and units in general population) and among women 45 units per week among women 45 units per week (compared to 5.4 units general (compared to 5.4 units general population)population)

Alcohol Consumption - NTORSAlcohol Consumption - NTORS

Heavy drinking can present serious Heavy drinking can present serious problems for a proportion of the problems for a proportion of the treatment population and it has been treatment population and it has been suggested that treatment programs suggested that treatment programs for drug users sometimes overlook or for drug users sometimes overlook or fail to respond effectively to alcohol fail to respond effectively to alcohol problemsproblems

Alcohol and other drugsAlcohol and other drugs

AmphetaminesAmphetamines CocaineCocaine BenzodiazepinesBenzodiazepines Club scene drugsClub scene drugs

• Particular risks with GHB & Ketamine Particular risks with GHB & Ketamine SolventsSolvents

Physical effects of drinkingPhysical effects of drinking

Raised LFT’s - Fatty liver - CirrhosisRaised LFT’s - Fatty liver - Cirrhosis GastritisGastritis PancreatitisPancreatitis Ca- Mouth, larynx, OesophagusCa- Mouth, larynx, Oesophagus HypertensionHypertension DiabetesDiabetes IntoxicationIntoxication Falls, accidents Falls, accidents

PhysicalPhysical

Sexual dysfunctionSexual dysfunction Flushed faceFlushed face AggressionAggression Interaction with other drugsInteraction with other drugs Withdrawal’sWithdrawal’s

• Tremors, Sweats etc.Tremors, Sweats etc.

Psychological effectsPsychological effects

DepressionDepression AnxietyAnxiety InsomniaInsomnia Suicide/attempted suicideSuicide/attempted suicide AmnesiasAmnesias HallucinationsHallucinations DementiaDementia

PhobiasPhobias Obsessive compulsive disordersObsessive compulsive disorders AggressionAggression Changes in personalityChanges in personality GuiltGuilt

SocialSocial Relationship problemsRelationship problems DivorceDivorce Work difficultiesWork difficulties Financial difficultiesFinancial difficulties Child care issuesChild care issues Housing difficultiesHousing difficulties Legal problemsLegal problems

• Drink drivingDrink driving• Burglary Burglary • ShopliftingShoplifting• Crimes of violenceCrimes of violence

Asking about AlcoholAsking about Alcohol

Should we do it, is it our job?Should we do it, is it our job? Do we have the skills?Do we have the skills? Do we have the support?Do we have the support?

Routine, as part of initial contactRoutine, as part of initial contact Opportunistically - In response to Opportunistically - In response to

further informationfurther information

Asking about alcoholAsking about alcohol Routine - Everyone is Routine - Everyone is

asked about their asked about their drinking (screening drinking (screening tools?) and tools?) and information is information is recorded in relation to recorded in relation to quantity, frequency, quantity, frequency, motive and motive and consequencesconsequences

Feedback and Feedback and interventions are interventions are based on the abovebased on the above

Opportunistic - Opportunistic - Certain Certain issues should make you issues should make you clarify drinkingclarify drinking• Smell or intoxicationSmell or intoxication• Evidence of cans or Evidence of cans or

bottlesbottles• Symptoms of Symptoms of

withdrawal- shaking, withdrawal- shaking, sweatingsweating

• Reports by - family, Reports by - family, professionals, selfprofessionals, self

• Alcohol related offencesAlcohol related offences• Stress, anxiety, low Stress, anxiety, low

mood, sleep mood, sleep disturbancedisturbance

Asking people how much they drinkAsking people how much they drink

the information which patients provide is the information which patients provide is sufficiently truthful to give an accurate sufficiently truthful to give an accurate indication of their risk from alcohol”indication of their risk from alcohol”

Royal College of GP’s (1986)Royal College of GP’s (1986) For most purposes and for most patients, For most purposes and for most patients,

self reported alcohol consumption will self reported alcohol consumption will provide a useful and satisfactory indicator provide a useful and satisfactory indicator of drinking behaviour.of drinking behaviour.

Assessing Alcohol UseAssessing Alcohol Use

Every client should be asked about their Every client should be asked about their drinking and specific information about drinking and specific information about this should be recorded in their notes/care this should be recorded in their notes/care planplan

Observable signs and symptomsObservable signs and symptoms• IntoxicationIntoxication• Smell (Alcometer)Smell (Alcometer)• Symptoms of withdrawalSymptoms of withdrawal

Tremors, sweatsTremors, sweats

• Physical stigmataPhysical stigmata Puffy/flushed face, Weight changesPuffy/flushed face, Weight changes

Assess current consumption:-Assess current consumption:-• What What • How much - ABV & QuantityHow much - ABV & Quantity• How oftenHow often• How long forHow long for• Why Why • Where, Who withWhere, Who with• DIARYDIARY

Alcohol StrengthsAlcohol Strengths

Draught beers/lagers/cidersDraught beers/lagers/ciders 3-6%3-6% ‘‘Special Brews’Special Brews’ 9%9% Table winesTable wines 8-14%8-14% Sherry, Port etcSherry, Port etc 15-22%15-22% SpiritsSpirits 35-40%35-40% LiqueursLiqueurs 20-55%20-55%

Abrupt CessationAbrupt Cessation

Alcohol Withdrawal ContinuumAlcohol Withdrawal Continuum

Drugs used in the treatment of Drugs used in the treatment of alcohol problemsalcohol problems

Drugs used in withdrawalDrugs used in withdrawal• Chlordiazepoxide (Librium)Chlordiazepoxide (Librium)• Chlormethiazole (Hemineverin)Chlormethiazole (Hemineverin)• DiazepamDiazepam

Drugs used in relapse preventionDrugs used in relapse prevention• Disulfiram (Antabuse)Disulfiram (Antabuse)• Acamprosate (Campral)Acamprosate (Campral)• NaltrexoneNaltrexone

Vitamin replacementVitamin replacement• ThiamineThiamine• Vitamin B complexVitamin B complex• PabrinexPabrinex

NaltrexoneNaltrexoneI hear you say?I hear you say?

When used as an adjunct to psychosocial When used as an adjunct to psychosocial therapies for alcohol-dependent or alcohol-therapies for alcohol-dependent or alcohol-abusing patients, naltrexone can reduce abusing patients, naltrexone can reduce

The percentage of days spent drinking The percentage of days spent drinking The amount of alcohol consumed on a The amount of alcohol consumed on a

drinking occasion drinking occasion Relapse to excessive and destructive Relapse to excessive and destructive

drinkingdrinking

Naltrexone therapy improves treatment Naltrexone therapy improves treatment outcomes when added to other outcomes when added to other components of alcoholism treatment. For components of alcoholism treatment. For patients who are motivated to take the patients who are motivated to take the medication, naltrexone is an important medication, naltrexone is an important and valuable tool. In many patients, a and valuable tool. In many patients, a short regimen of naltrexone will provide a short regimen of naltrexone will provide a critical period of sobriety, during which the critical period of sobriety, during which the patient learns to stay sober without it.patient learns to stay sober without it.

How does Campral work?How does Campral work?

Acamprosate (Campral) reduces the Acamprosate (Campral) reduces the craving for alcohol by inhibiting a craving for alcohol by inhibiting a chemical in the brain called gamma chemical in the brain called gamma aminobutyric acid (GABA). Several aminobutyric acid (GABA). Several studies have indicated that it may studies have indicated that it may help drinkers remain abstinent help drinkers remain abstinent

Does the Client use alcohol?

If No:- Record, Keep under review

If Yes:- How Much, How Often, etc

Is the clients alcohol use a factor in their presentation?

If Yes - Give feedback/Info

Does the individual want to make changes in their alcohol use?

If Yes:- Offer options -Set Goals -Action Plan - Monitor Active Treatment/Relapse Prevention

If No - Plan management accordinglyEngage/Persuade/Set Boundaries

What practical steps could you take What practical steps could you take to address alcohol use amongst your to address alcohol use amongst your drug using clientsdrug using clients• On an individual basisOn an individual basis• On an organisational basisOn an organisational basis

What may be the barriers to addressing alcohol amongst your clients

Practice Issues to considerPractice Issues to consider

Harm MinimisationHarm Minimisation Hepatitis C/BHepatitis C/B Increased risk associated if also Increased risk associated if also

using Benzodiazepinesusing Benzodiazepines Individuals substituting alcohol for Individuals substituting alcohol for

opiates while stabilising on opiates while stabilising on methadonemethadone

Staff TrainingStaff Training Risk assessment - Overdose etcRisk assessment - Overdose etc

Other IssuesOther Issues

Baseline assessmentBaseline assessment Inclusion in careplanningInclusion in careplanning Inclusion in outcome monitoringInclusion in outcome monitoring Policy for managing alcoholPolicy for managing alcohol

• Ongoing assessment (Use of alcometer)Ongoing assessment (Use of alcometer)• Managing alcohol useManaging alcohol use

Working with alcohol servicesWorking with alcohol services

• Boundaries for acceptable behaviour (No Boundaries for acceptable behaviour (No alcohol allowed in clinic etc)alcohol allowed in clinic etc)

Do you Need To?Do you Need To?

Change prescribing practice?Change prescribing practice?• Daily pickupDaily pickup• Supervised consumptionSupervised consumption• Withholding scripts (Alcometer)Withholding scripts (Alcometer)

• Do they above make a difference?Do they above make a difference?

Skills Skills

Assessment - Screening tools, drink diary, Assessment - Screening tools, drink diary, pro’s and con’s, exchanging info.pro’s and con’s, exchanging info.

Readiness to change taken into account - Readiness to change taken into account - Importance and confidence, MotivationImportance and confidence, Motivation

Dependency issuesDependency issues Goal settingGoal setting Problem solvingProblem solving Dealing with relapseDealing with relapse Coping with cravingsCoping with cravings

NTORSNTORS

All drug services need to look at All drug services need to look at strategies to keep alcohol on their strategies to keep alcohol on their agendaagenda

There is no longer a Berlin WallThere is no longer a Berlin Wall