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KaarloSimojoki

Providing Care for an Alcohol or Drug Abuser

Essentials

  • Acute state of intoxication should not be a cause to refuse the patient appropriate services and treatment.
  • The possibilities offered for detection of abuse problems and referral to therapy in association with visits to primary, occupational and secondary care should be utilized.
  • In cases of overdosing, the patient is followed up and treated.
  • Information and other services regarding injection and sexual hygiene should be made available to those drug users who are otherwise not within the reach of health care services, without requiring them to stop abuse or seek help as a condition to receiving help.
  • Find out about locally available services and local regulations regarding reimbursement of relevant services to treat substance abuse and associated health problems. Some special regulations may exist for a person's right to acquire urgent care (e.g. pregnant women with substance abuse).

The drug problem

  • Drug use is associated with several health problems, including infectious viral diseases (hepatitides and HIV).
  • In addition to regular drug users there are those who experiment with drugs or use them occasionally. Identifying at an early stage also persons belonging to the latter groups is especially important in order to prevent problems developing.
  • The threshold of trying new e.g. designer drugs is low, leading easily to long-term abuse and new types of harms.
  • Chronically dependent users have to sell drugs to new user groups to fund their own use. Intravenous use of drugs is common to maximize the effect.
  • Hepatitides and HIV are spread by the use of shared needles and syringes. Unhygienic injection techniques cause local and systemic infection complications as well as necroses and amputations of terminal parts of the extremities.
    • The safety profile and cost of new drugs for hepatitis C have developed favourably and hence treatment for hepatitis C is available more extensively than earlier. Find out about local strategies and policies concerning treatment of persons with hepatitis C.

Referral of drug abusers

First aid and follow-up care

  • See also Treatment of drug addicts Treatment of Drug Addicts.
  • Intravenous heroin overdosing may cause immediate respiratory arrest. Naloxone is the specific therapy, see Treatment of Poisoning.
  • Buprenorfine is currently the most commonly abused opioid. The response to naloxone is poor especially in mixed use, which is very common and includes sedatives and alcohol as central elements.
  • Designer drugs cause increasingly adverse effects that require urgent care but they are not detected by standard screening tests. Use of such drugs should be suspected if the patient is very confused but has not used alcohol and the drug screening test does not detect traditional drugs.
  • Following successful initial care the patient should be followed up in the emergency unit (depending on the local service guidance).
  • Patients with psychosis caused by amphetamine or other stimulants, designer drugs or hallucinogenics should be referred to psychiatric care as emergencies when the criteria of involuntary care are met.
    • The psychosis is often transient, except in designer drugs that warrant a longer somatic monitoring. Referral to further treatment is the responsibility of the treating psychiatric unit.
  • Further care can be arranged in most cases within separate drug withdrawal units. Specific assessment and withdrawal units are available for persons younger than 18 years of age Substance Abuse of Adolescents.
  • In order to ensure appropriate care, acute withdrawal symptoms may be necessary to treat as an emergency in opioid-dependent persons who are hospitalized for a medical problem such as septicaemia, a psychiatric problem, or some other condition.
  • Otherwise, opioid withdrawal and substitution therapy for those who seek for acute drug rehabilitation should be the responsibility of specialized units Treatment of Drug Addicts.

Health counselling services

  • Counselling services are offered anonymously.
  • The service offers counselling on infectious diseases and sexually transmitted diseases, vaccinates against hepatitis A and B, performs HIV and hepatitis tests, as well as pregnancy tests, exchanges syringes and needles, and gives out condoms. Nowadays an increasingly important task is to find those willing to receive further therapy and to refer them to therapy.
    • Depending on the national strategy concerning hepatitis C, pharmacotherapy for it may belong to these services.
  • The staff usually includes trained health care personnel and social workers as well as nowadays also previous drug users trained for the task.

Withdrawal therapies

  • Directed mainly at patients dependent on stimulants, designer drugs or opioids Treatment of Drug Addicts
    • There is often concomitant use of benzodiazepines in overdoses: strong craving for drugs and the risk of seizures with unconsciousness and convulsions should be taken into account.
  • Possible dependence on cannabis must be taken into account when planning rehabilitation.

Referral to opioid replacement therapy

  • Opioid dependency often requires specific drug therapy that is administered in specialist units Treatment of Drug Addicts. Find out about local requirements.

Rehabilitation

  • Entails long-term therapy in a rehabilitative programme or an outpatient setting or, as required, within an institution. The goal is abstinence or reduction of adverse effects.
    • In the initial withdrawal stage, an institutional setting supports the patient's struggle to rid him-/herself of the group of active users.
  • The early remission takes 3-6 months during which phase support is of particular importance. Some patients may need medication for psychiatric symptoms in this phase.
    • The withdrawal therapy for benzodiazepine dependency often also takes place in this stage, but its implementation should be based on individual assessment.
  • If needed, further rehabilitation may be arranged within special services of primary health care or in a non-pharmacological withdrawal programme of a therapeutic community.
  • During the active therapy phase, and particularly after it, many patients benefit from a supportive network of peers that consists of former users (NA groups).
  • A large share of those addicted to opioids and whose abstinence attempts have failed need substitution therapy Treatment of Drug Addicts.

Referral of persons with alcohol dependence

  • Options
  • Cooperation between social and health services is important: overlapping activities are avoided and the risk of patients being left without proper services is prevented.
  • Patients with alcohol or drug abuse problems often also have mental disorders requiring treatment and hence collaboration with specialized psychiatric services is necessary.
  • Motivational discussion may assist in steering the patient to care and in implementing the care. Different therapies (cognitive behavioural therapy, solution-focused therapy, psychodynamic or interpersonal therapy) or CRA (community reinforcement approach) or 12-step programmes are practical alternatives.

Special treatment services

  • Occupational health services and primary health care centres
    • Treatment of alcohol dependence in its early phase or when it is of moderate severity when counselling and monitoring of alcohol consumption together with medication with nalmefene, naltrexone or disulfiram are sufficiently effective treatment modes.
  • Detoxification and rehabilitation clinics and youth clinics run by communities or foundations
    • Provide ambulatory services for alcohol or drug abusers and their families. The employees of these units are professionals in health care and social work as part of a multidisciplinary team.
    • Outpatient-based detoxification
    • Individual, family or group therapy
    • Counselling in social problems, treatment of minor health problems
    • The services are provided free of charge. Usually an appointment must be made in advance.
    • At some clinics an appointment with a nurse can be made without prior reservation.
  • Detoxification and withdrawal units
    • The patient is helped to stop the use of alcohol or drugs within a short period (5-12 days) in an inpatient setting.
    • Enabling of physical rehabilitation and solving of social problems
  • Rehabilitation centres
    • Inpatient settings providing detoxification, withdrawal and rehabilitation services usually for 4-6 weeks, sometimes longer
  • Assisted living units
    • Suitable for persons who are in need of continuous support and assistance in independent living because of limited functional capacity
    • Some units may provide meal and laundry services etc.
    • The aim is to enable moving to normal housing later on.
    • Special units exist specialising in the treatment of patients with alcoholic dementia.
  • Patients' associations/guilds
    • Registered associations run by clients of alcoholism clinics. The guilds provide aftercare and support after other treatment has been completed.
  • AA groups Alcoholics Anonymous and other 12-Step Programmes for Alcohol Dependence
    • Anonymous peer groups founded by alcoholics
    • A similar group for relatives or friends of alcoholics is called Al Anon.
    • The groups accept all alcoholics or members of their families or friends.
    • The groups provide a place for discussing problems associated with alcohol and support efforts to remain abstinent.
  • Psychotherapies
    • Different modes of psychotherapies (cognitive, behavioural, brief or family therapy) and different combinations of other therapies suitable for the treatment of alcohol dependency are used at some clinics or institutions.
  • Occupational health
    • Occupational health care units should always participate in the referral of alcohol or drug abusing employees to treatment and in making arrangements and planning the treatment and rehabilitation.

Evidence Summaries ⬆