Samuel West, 19 years old, presents for review of cellulitis of his arm. He was treated at the local hospital initially and has been discharged on oral antibiotics.
In your assessment of Samuel you record that he has had previous episodes of cellulitis and you note the presence of 'track marks' on both arms.
General principles in history include:
General principles in examination include:
Standard questionaries used to assess substance abuse:
The 'Stages of Change' model allows the practitioner to fully understand the process where people move through different stages of preparedness to change.
Stage 1: Pre-contemplation
Here, people are not thinking seriously about changing and not interested in any kind of help. People in this stage say they do not consider it is a problem. They tend to defend their current bad habit(s) and be defensive in the face of other people's efforts to pressure them to quit.
Stage 2: Contemplation
Here, people are more aware of the personal consequences of their bad habit and spend time thinking about their problem. Although they can consider the possibility of change, they tend to be ambivalent (weighing the pros and cons of quitting or modifying their behaviour). Although they think about the negative aspects of their bad habit and the positives associated with giving it up (or reducing), they may doubt that the long-term benefits associated with quitting will outweigh the short-term costs. It might take from a couple weeks to a lifetime to get through the contemplation stage! On the plus side, people are more open to receiving information and to actually use it and to reflect on their own feelings and thoughts concerning their bad habit.
Stage 3: Preparation
Here, people have made a commitment to make a change. Their motivation for changing is reflected by statements such as: "I've got to do something about this - this is serious. Something has to change. What can I do?"
Stage 4: Action
Here, people believe they have the ability to change their behaviour and are actively involved in taking steps to change their bad behaviour by using a variety of different techniques.
This is generally the shortest of all the stages: it generally lasts about 6 months, but it can be as short as one hour! This is the stage when people most depend on their own motivation and willpower as they are making overt efforts to quit or change the behaviour and are at greatest risk of relapse. They will review their commitment to themselves and develop plans to deal with both personal and external pressures that may lead to slips. They may use short-term rewards to sustain their motivation, and analyse their behaviour change efforts in a way that enhances their self-confidence. People in this stage also tend to be open to receiving help and are also likely to seek support from others (a very important element).
Stage 5: Maintenance
Maintenance involves being able to successfully avoid any temptations to return to the bad habit. The goal is to maintain the new status quo. Here, people tend to remind themselves of how much progress they have made. They constantly reformulate the rules of their lives and as they acquire new skills to deal with life and avoid relapse. They are able to anticipate the situations in which a relapse could occur and prepare coping strategies in advance.
Relapse
Most people experience relapses along the way to permanent cessation or stable reduction of a bad habit. In fact, it is much more common to have at least one relapse than not. Relapse is often accompanied by feelings of discouragement and seeing oneself as a failure. While relapse can be discouraging, the majority of successful quitters do not follow a straight path to a life time free of self-destructive bad habits. Rather, they cycle through the five stages several times before achieving a stable life style change. Consequently, the Model considers relapse to be normal.
The overall shape of the sessions includes:
The MI approach is non-confrontational and person-centred. By its nature it is transparent and puts the onus back onto the person to decide where on the change cycle they feel comfortable. The key to management is to engage the patient in articulating for themselves the positive and negatives about their drug use. This can lessen defensiveness and lead to more open conversation.
As there are things that can be done at each stage, the clinician can feel useful rather than helpless. MI is about patients finding their own motivation rather than being told by their doctor what is good for them. It may be useful to work with the patient to develop a motivational matrix to help them move from the pre-contemplative to the contemplative and subsequent stages.
Doctors need to walk a fine line between drawing out what a person knows about their drug use and informing the patient about the medical consequences of their drug use.
Ongoing pharmacological and psychological management strategies that may be useful
There are a wide range of treatment options for patients with heroin dependence.
To become drug-free, dependent users have to overcome the compulsion of drug use, ongoing cravings and the physical adaptation to chronic drug use. They also have to address psychological and social issues that may be underlying reasons for using drugs or the consequences of a drug-using lifestyle. This often requires a radical rethink of how they spend their time and who they associate with.
Recovery from severe and long-standing dependence is likely to require substantial physical, psychological and lifestyle readjustments, which can take years.
Patients may require several different types of treatments in order to overcome their dependency.
While detoxification is not considered a treatment, it is often the first step in overcoming drug dependence.
Stage 1: Detoxification
Detoxification refers to the elimination of heroin or other drugs from the body and takes about one week. People may detoxify in hospital, specialist drug and alcohol units, outpatient clinics or at home. Two distinct medication approaches to manage heroin withdrawal are:
The provision of detoxification services entails: assessment; treatment matching; planning for withdrawal; supportive care, and linkages with services for further treatment and support.
Detoxification in opioid dependence should always be considered as part of a structured treatment approach.
Stage 2: Immediate treatment to initiate and maintain abstinence
Group programs providing education and supporting public, NGO and private settings:
It is recommended that patients participate in self-help groups, as participation opposed to just attendance is related to effectiveness.
Buprenorphine treatment: Two buprenorphine products are registered in Australia: Subutex (buprenorphine hydrochloride) and Suboxone (buprenorphine hydrochloride and naloxone hydrochloride), both taken sublingually. Suboxone minimises potential misuse and diversion of buprenorphine, as buprenorphine-naloxone combination preparations are less likely to be injected than mono preparations containing only buprenorphine. This makes Suboxone the preferred option for 'takeaway' doses.
Naltrexone is used in patients who have ceased opioid use with the aim of preventing relapse to drug use. Psychosocial support is an integral component of naltrexone maintenance treatment. Naltrexone treatment for dependence is a long-term undertaking, as relapse to heroin dependence can occur even after two or three years of treatment.
Stage 3: Changing patterns of thoughts and behaviours/Staying well
Substance use disorders (SUDs) are heterogeneous conditions characterised by recurrent maladaptive use of a psychoactive substance associated with significant distress and disability. Our understanding of the nature of substance use patterns has improved, leading to greater specificity of psychosocial and pharmacologic treatments, with evidence for the efficacy and cost-effectiveness of these approaches.
Cognitive Behaviour Therapy, Motivational Enhancement Therapy (MET) have been useful for younger people while Interpersonal Therapy, Dialectical Behaviour Therapy (DBT), Family Therapy are some treatments that may be of use. All of these can be personalised to the individual, according to style, motivation, duration and severity of addiction. In younger people, especially if living at home, involving the family can be very helpful.
NDARC has some resources for addicts who have anxiety disorders which have potential use for Samuel if anxiety is driving his addiction and dealing with his cannabis problem. These would be applied after the heroin issues are dealt with.