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  • Most commonly injected thing in NSPs is oxycodone + fentanyl (prescribed opioids).
  • Most commonly used drug in Australia is alcohol
    • Identify alcohol dependence
      • alcohol dependence --> no thiamine absorption --> wernecke's encephalopathy
    • Acute Problems:
      • Violent behaviour, drink-driving, death (depressant of resp. system), risky sexual activity
    • Chronic Problems:
      • Liver disease (cirrhosis --> ascites), dementia
    • Know how to manage alcohol withdrawal; 5% mortality associated with withdrawal
  • Spinal injury ward - most commonly motor vehicle accidents (due to alcohol or other substances; very young)
  • Doctors use oxycodone and fentanyl, as well as alcohol
  • National drug strategy: policy of harm minimisation
    • HM is not stopping something happening - but reducing the risk
    • HM = supply reduction, demand reduction and harm reduction
  • Harm reduction includes stopping people from smoking e.g. mouth cancer photos on box
  • Harms of cannabis:
    • most used illegal substance in Australia
    • often mixed with nicotine (withdrawal = anxious, restless)
    • Can increase risk of schizophrenia if predisposed
  • Alcohol associated with rights of package, sports; there are alcohol advertisements targeted at various subpopulations e.g. mixed drinks that are focussed on young girls and are more palatable. Acute brain injury - high toxicity
  • Remember always ask about drugs, sex and suicide
    • If you don't ask you don't get
  • Age group for prescribed medication use is in 60-80
    • Death, chronic illness, isolation, depression, losing identity
  • Brief intervention - ask (don't ask don't get), talk about their problem, make them about themselves, spend 3-5 minutes on this topic. Most effective in GP practice and hospital ED. Make it about their drug use and their life
  • Supporting people with drug use - if they want treatment, you need to have services (it doesn't work in remote settings)
  • Looking for: insight, resilience, willpower. People tend to learn coping chemically (e.g. chronic pain), motivation; hardest with diabetes (because something that used to be OK is now not allowed). Only 2% of diabetics follow the rules laid down by health professionals (lifestyle change: diet and exercise). People focus on the medications.
  • Substance abuse is a chronic relapsing condition
  • Support the efforts of people who are trying to increase social inclusion
  • Memorise the three pillars of harm minimisation
    • Demand reduction
      • Education
      • Increase cost (eg. taxation)
      • Delay initial usage (eg. age restrictions, education)
    • Supply reduction
    • Harm reduction
  • Switzerland - substance abuse is less of a problem because those people are in the community
    • Australia/France - putting all the drug users together - they reinforce their vices.
  • NSPs - people nearby think it will increase crime etc (they don't want them next door)
    • Business people - think it invites more drug use to the area
    • Evidence doesn't support this
    • Just because you make needles/condoms free, then it doesn't increase these behaviours
    • Don't really want to promote condoms in monogamous relationship
  • School education doesn't work for preventing drug use; people are learning from their iPhones etc
  • Harm minimisation w.r.t. drug use is the same as not washing hands
    • Brushing teeth is another example
    • Everything comes down to personal responsibility
  • USA - zero tolerance and prohibition has been used for centuries, but it doesn't work
    • Prohibition results in increased use
    • Law enforcement efforts can be included in demand reduction; lock up the people who are dealing
  • Addiction is a brain disease, even though the first use may have been conscious choice
    • Treatment: Repeat the message over and over
  • Alcohol
    • Taxes
    • Close earlier, no shops open
  • Newcastle
    • Pubs close early, don't use glasses (glassing is the most common injury), no shots after 11
      • Most negative things happen after midnight - because people are already drunk so they keep drinking
      • Pubs closing at 7pm --> domestic violence
    • Less violence
    • Would be better if they had more transport
    • Prohibition areas
  • Pharmaceutical substances
    • Supply reduction - concentrate on doctors prescribing the drugs; identify doctor shopping; depot for chronic problems; pharmaceutical companies do not want their name associated with illicit use; pharmacies should keep track of them (point of dispensation);
      • once you get a prescriber number, register your number with medicare for the doctor shopping system
    • Harm+Supply reduction - get rid of oxycodone-containing gel because IV gel causes necrosis. Now they give out a tablet that people can't inject
  • Xanax (benzo) - short term anxiety
    • There are tablets that have 10 times therapeutic dose. This is outrageous.
  • There aren't overarching systems to prevent doctor shopping - they can only be implemented between doctor, patient and pharmacy
    • They have an overarching system in Tasmania
  • Before NSPs - there was sharing of needles; problem with HIV
    • Public health reporting identified epidemic
    • Health minister tried to stop NSPs
    • Community opposes any changes
    • Bipartisan approach to NSPs came in
    • Alex Wodak was threatened to stop NSP or lose his job, but it was very successful so then they started liking him
    • HepC - if you don't clear it in the first 12 months, then you get HCC and cirrhosis (waiting for liver transplant etc)
      • IDU contract HepC early; highly infectious; people inexperienced early
      • Sharing tourniquet is #1 for sharing
      • Prison system - high hepC and HIV. NSP would be good. Prisons don't want to admit there is a problem.
      • Supply to prison system - cops and guards sell it; corruption is universal
      • 80% of people leave prison HepC negative
  • Drug mules
    • Only paid $1000
    • Eat the drug in a condom, wait for it to poo out
    • There is so much cocaine in the condom that you can't do a colonoscopy since rupture the condom --> heart attack
    • Corruption occurs everywhere
  • Alcohol harm minimisation
    • Have an alcohol drink, then have 2 glasses of non-alcohol drink; vegemite on toast (B12); thyamine tablets
    • Liver can tolerate 1-2 standard drinks per hour


Questions

  • 1. During the early 1980s, what was the prevailing policy on injectable illicit drugs? What were the arguments for - and against - that policy?
  • 2. What were the arguments for - and against - introducing a NSP program?
  • 3. What is a harm reduction policy? What is a tough on drugs (‘zero tolerance’) policy?
  • 4. Compare and contrast the features of these two policies?
  • 5. Summarise the dilemmas inherent in the harm minimization policy. (refer to Reading 2)
  • 6. What have you observed in your current clinical attachment that is relevant to harm reduction in general - and NSPs in particular?
  • 7. What do you know of the policies on illicit drugs in other countries?
  • 8. What are the current thoughts on approaches to address illicit drug use?


CMT discussion will explore how one might modify the application of harm minimization policy and The National Drug Strategy 2010-2015 to specific health problems in sub-populations, including:

  • 1. Alcohol excess in Aboriginal communities (refer to Reading 3)
  • 2. Comment on how the substance use problems might affect Australians in different settings such as rural and remote areas, compared to urban settings.
  • 3. Comment on the impact of substance use in younger and older Australians.
  • 4. Comment on the possible opposition to this approach from different sections of the society (refer to Reading 2)
  • 5. Comment on the significance of people in custodial settings who face substance use issues, and applying the harm minimisation approach in these settings (refer to Reading 4)


What?

?||Why y||How? ?

2012

2||* NSPs – 1’ 2’ and pharmacy – fit packs don’t all contain filters – used to be an exchange program.

  • Decrease the criminalization and promote safe disposal of needle – public hotline
  • Range of clients – age
  • Methadone clinics – give education and ρeferral to health services (+ opportunistic services)

)||* NSP – trial results – HIV low and stable – decrease health care cost

  • HCV rates haven’t decreased (higher baseline, higher infectivity) – hep c doesn’t have stigma

a||* Harm minimization – decrease supply, decrease demand, harm reduction

  • Harm


1980

0||* MSM – US to AUS

  • Etiology unknown, virus? God?
  • Politics of health care
  • Concern amongst medical community
  • Wovak NSP at St Vinnies
  • MSM > IDU > Sex Workers > general population

n||* Evidence NSP trials – Netherlands, Scotland, Australia a||

NSP – needle syringe exchange program – primary, seconday and pharmacy – 1’ and 2’ have a lot of allied health vs the pharmacy – provided in packs, not ever program provide filters – filters are needed. (they don’t have to do the 1 for 1 exchange) – fit pack (you can put it back in the pack and dispose in a regular bin)

Cabramatta 80/90’s zero tolerance = increase spread of drugs to other areas + increase problem for justice and health services