Dilemas in SUD treatment Flashcards
What is SUD
A rewarding seeking behaviour
that gets out of control and
leads to harm
Harm to not just self but other people aswell
What does research suggest is the most dangerous drug
2020 Lancet published that Alcohol is the most dangerous drug to both self and other.
Followed by Heroin, crack, metamphetamine
Different tables change the order of these but these are usually the most dangerous
Dilemas of SUD
Which drug to prioritise
What to do/how to treat
What to aim for:
-immediate/sustainable
-effective/cost-effective
-pragmatic/idealistic
Treatment
-does not differentiate between licit or illicit substances
-takes into account legal status and relevant effect on the person and impact on access, compliance and completion.
(eg someone struggling with an addiction to an illicit substance might face additional legal barriers, such as potential criminal charges. These barriers could affect their willingness to seek treatment and adhere to the recommended interventions. But a person using a legal substance may have a different set of challenges, such as the perception that their substance use is socially acceptable, making them less likely to seek help.
What substances ?Heroin, cocaine/crack, amphetamines/crystal meth, benzodiazepines, alcohol, new substances
what are the principles of European Drugs Strategy 2021-2025
3 pillars:
1. supply,
demand reduction and harm reduction.
(supply: Control of drugs at the border and the synthesis of drug within the country,
Demand reduction: reducing and preventing drug use in the society (recovery and prevention treatment)
Harm reduction: vaccinations, syringe distribution)
2 principles: public health approach, evidence based
3 components in demand reduction:
Prevention
Treatment
Recovery/ reintegration
3 themes: evaluation, education, coordination
Change of policy ovevr the years
Importantant of the policies to be flexible and change with new evidence
1998: Increase number of people in treatment
2008: No change
2010: DRUG STRATEGY 2010
Reducing Demand, Restricting Supply, Building Recovery :
Supporting People to Live a Drug Free Life
2010 policy: big change
Major reduction in the investment of the drug system – 45reduction in the number of pshyciatrist working
Too much emphasis on the abstinence approach
2017 Drug Strategy- same
2021 From harm to hope: A 10-year drugs plan to cut crime and save lives
1.delivering world-class treatment and recovery services – rebuild local authority commissioned substance misuse services, improving quality, capacity and outcomes
- rebuilding the professional workforce – develop and deliver a comprehensive substance misuse workforce strategy
Dilemmas in the treatment of opioid dependence
Users of illicit substances (heroin or opioids) are treated by giving them opioid replacement therapy- methodone, bunephorine- dilemma is that is this approach against recovery or the first step towards recovery
1.ORT & Recovery:
Balancing opioid replacement therapy (ORT) as harm reduction vs. complete abstinence as recovery.
2.ORT & Reintegration:
Integrating ORT users into society while avoiding dependency concerns.
Recovery & Treatment Exit:
Timing the transition from treatment to recovery to prevent relapse or stagnation.
3.Reintegration & Treatment Exit:
Navigating societal reintegration after treatment exit without losing support.
4.Treatment Exit & Risks:
Addressing relapse risks when transitioning from treatment to self-sustained recovery.
Evidence in support of ORT
Replacement treatment effective and cost –effective in reducing crime and health consequences (Ward et al, 1997; Marsch, 1998).
Harm minimisation compatible with maintenance (NTA, 2007), and effective in reducing prevalence of BBV (Health Protection Agency, 2006).
UK target of doubling number of PDUs in treatment achieved (DH 1998; NTA, 2010)
Evidence against ORT
ORT is associated with prolongation of time required to achieve abstinence (Best et al, 2006)
30-50% achieve stability on prescribed medication (Gossop et al., 2003)
Less than 10% exit treatment abstinent (NTA, 2010)
81% of people using heroin wished to become drug free (NTA, 2006)
More evidence for abstinence associated treatment
Little is known about effective abstinence orientated approaches
Psychosocial treatments alone not adequate or superior to any other type of treatment (systematic review Mayet et al., 2004). Limited evidence on cost effectiveness (McLellan et al. 1993; Kraft et al, 1997; Avants et al, 1999; Drummond et al, 2004)
Abstinence-oriented treatment should include education on post-detoxification vulnerability and a need for wider psychosocial rehabilitation and support (NICE, 2008a).
What did NICE say about Contingency management
Cognitive behavioural therapy
in 2008 for opioid therapy
CM during or after opioid detoxification is effective in enhancing abstinence and completion of treatment, either with short or longer-term interventions.
CBT should be offered to those stabilised on maintenance treatment or have achieved abstinence.
Existing evidence is generated in USA, implementation to the UK proven problematic and controversial (mostly CM), (Kouimtsidis & Drummond, 2010).
What is Recovery defined as
Recovery principles:
Meaningful & satisfying life defined by the person
Hope
Self-management-self agent
Clinicians as coaches
Recovery associated with social inclusion
Personal identity, separate from illness or disability
Personal qualities of staff as important as qualifications
Family and peer support crucial
recovery capital
The concept of recovery capital underscores the idea that successful recovery goes beyond just abstaining from substance use; it involves building a strong foundation of resources and skills that empower individuals to create a meaningful and fulfilling life without relying on addictive substances.
Personal RC:
physical (physical health, financial assets, health insurance, clothes, food etc
& human (values, knowledge, skills, self-awareness, self-esteem, self-efficacy)
Social RC: relationships (family) & social
Community RC: community attitudes, policies, resources
The challenges related to addiction treatment and recovery
Person-Centered Approach:
Balancing standardized treatment protocols with the need for individualized care.
Tailoring treatment to each person’s unique needs, preferences, and circumstances.
Overcoming potential biases and assumptions that might hinder understanding the person’s perspective.
2.Shift from Harm Reduction to Recovery and Reintegration:
Transitioning from harm reduction approaches, which focus on minimizing negative consequences of substance use, to promoting complete recovery and societal reintegration.
Navigating the balance between providing immediate safety through harm reduction and fostering long-term recovery goals.
3.Public Health vs. Public Order/Safety:
Balancing the priority of public health (providing treatment and support) with the need to maintain public order and safety (addressing criminal aspects of substance use).
Collaborating with law enforcement while ensuring that punitive measures do not hinder treatment accessibility.
Stages for addiction treatment.
Self-Referral:
Allowing individuals to voluntarily seek help for their addiction, often a critical step in acknowledging the need for treatment.
Starting Within 5 Days:
A prompt response to ensure that individuals can begin their treatment journey quickly after expressing their desire to get help.
Initiation and Titration - 2-4 Weeks:
The initial phase of treatment, during which appropriate medications and dosages are determined, often involving a period of adjustment and monitoring.
Stabilization - 3 Months Retention with Counseling and GP Reviews:
A period of about three months focused on achieving stability in both physical and psychological aspects of recovery.
Inclusion of counseling sessions and medical reviews by a General Practitioner (GP) to address various aspects of recovery.
Gradual Reduction:
A process of slowly tapering off medications or substances under medical supervision to minimize withdrawal symptoms and potential relapse.
Residential Rehabilitation:
A comprehensive treatment program that involves residing at a treatment facility for an extended period.
Provides structured support, counseling, therapies, and a therapeutic community environment.
