Adding Alcohol To the Adding Alcohol To the Equation?Equation?

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?

"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

The Effect Of HeroinThe Effect Of Heroin

And Titrated MethadoneAnd Titrated Methadone

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

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

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

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

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

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

Abrupt CessationAbrupt Cessation

Alcohol Withdrawal ContinuumAlcohol Withdrawal Continuum

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

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