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NIMHANS Digital Academy
Project VKN NIMHANS ADDICTION ECHO
Substance Use
and Abuse
Prabhat Chand MD, DNB, MNAMS
Centre for Addiction Medicine
Dept of Psychiatry
NIMHANS
[email protected]
Note: These slides can be reproduced as a whole with the acknowledgement to the author/presenter and NIMHANS 352
ECHO.
For any modifications please contact the author/presenter for due permission by email.
Email: [email protected] Mobile No. 9480829844
This material is for the participants enrolled into
“Foundation of Addiction (FoAM) ECHO: A Digital course”
Learning Objectives
- Understanding Harmful use or Abuse or Risky use
- Screening and its Significance
- What is ASSIST (Alcohol, Smoking and Substance
Involvement Screening Test)
- Understanding Nuts and Bolts of ASSIST application
- e-ASSIST (Demo)
- Conclusion
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Introduction
● Unhealthy
Alcohol/Substance use is
very common , often
underdiagnosed and poor
help seeking
● Road traffic accident,
Violence, Drunk driving
are common challenges
Pace & Uebelacker 2019 354
Alcohol Use In India
● In India: 27.3% male consumed alcohol
and 1.6% Female in last six months
● Heavy consumption : Spirits and more
than 4 drinks in single occasions : 43%
● Physical fights/Day time Consumption>
20%
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National: Around 6 Crore
Problem Users + 3 Crore
Dependent Users of Alcohol
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Regional Study
A Prevalence studyHow many are drinking Hazardously? in a rural village of MP n=3220
Consuming alcohol in last 12 months: 23.8% Men and 0.6%
Women
Among Drinker 33.2% Hazardous
Drinking
3.3% Harmful Drinking
5.5% Dependence
2.8% took any treatment (Rathod et al. 2015) 357
PROACTIVE HEALTH CARE
SHIFT FROM 358
EPISODIC & REACTIVE TO CONTINUOUS PROACTIVE
millionhearts.gov
What is Screening Screening is
Application of
simple test to
determine if the
person has certain
conditions
www.flaticon.com
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Difference between Screening and Diagnostic Test Diagnostic Test
Screening test Done on Sick or similar
Number of symptoms,Sign and Lab findings
Done on Apparently Healthy person More Accurate
Based on Cut off points More Expensive
Less accurate Used for treatment
Less expensive Reactive approach
May not be basis for Treatment
Proactive approach to prevent future morbidity
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Criteria of a Good Screening Tool
● Acceptability: Safety, simplicity and ease of
administration
● Reliability/Repeatability: Same result on same
individual applied multiple time
● Validity: Accurately measure what it is intended to be
● Cost: Who administers the test, how long it take
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Goals of Substance Use Screening
● To Identify Individual who are at risk for developing
Alcohol or Drug related Problems
● To identify clients who need further assessment to
diagnose SUD
● Develop a plan to treat them
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Role of Health Professionals in Screening
● Often is the first point of contact
● People feel more comfortable and open with Primary
health providers to discuss
● Expect them to involve all aspects of mental health and
well being
● Find more credible
● Unique opportunity to provide promotion, prevention
and holistic care for low level of Substance use
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
ASSIST ● What is the ASSIST
● What does the ASSIST
Alcohol, Smoking and
Substance Involvement do
Screening Test ● Why use ASSIST
● Development of the
ASSIST
● Where to use ASSIST
● Who can use ASSIST
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
What is ASSIST 365
● Alcohol, Smoking and Substance Involvement
Screening Test by World Health Organization
● Brief 8 Item Questionnaire
● Takes 10 minutes to administer
● Developed mainly at Primary Health provider and
Welfare setting
● Can be used cross culturally
The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
What does the ASSIST do
● Screen for Risky Substance use for following categories
- Tobacco, Alcohol, Cannabis, Cocaine, Amphetamine like stimulants,
Sedatives, Hallucinogens, Inhalants, Opioids and “Other Drugs”
● Determine Risk for each Substance
- Low, Moderate and High risk
● Provide opportunity to start discussion with the client about the
Substance use
● May not be helpful if someone is clearly “dependent” on a Substance
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Overview of ASSIST 367
● Life time use :Q1: Ever used
● Last 3 months:
Q2: Frequency of Use
Q3: Desire to Use
Q4: Health, Social, Legal, Financial Problems
Q5: Failure to fulfill role Obligations
● Life time Use
Q6: Concern by Others
Q7:Failed attempt to control use
Q8: Injecting Behavior
The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Why Use ASSIST
● People use Substance for pleasure
● In few of them, it can increase and may pose problem
● Screen them early will have significant help to prevent
addiction as well as related harm
● Can possible by use ASSIST and Feedback in any
Opportunity as a “Wellness” strategy
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Development of the ASSIST
Developed in 1997 in Four phases
● Phase I (1997-1999)
Planning and ASSIST development. and International feasibility and reliability
study of the ASSIST.
● Phase II (2000-2002)
International validity study of the ASSIST and Feasibility study of brief
interventions linked to the ASSIST
● Phase III (2002-2007): International study of effectiveness of a brief
intervention linked to the ASSIST (randomized controlled trial including India).
● Phase IV (2008-2011): Development of effective and sustainable models of
ASSIST-based Brief interventions. Dissemination, implementation and evaluation
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Cannabis: Effect of ASSIST -Brief
Intervention
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Where to use ASSIST 371
Can be used any settings
- Primary health care
- Wellness centre
- Correctional setting (Prison)
- Community care
- Speciality centres
- HIV clinics
- NGOs
- Psychiatry
- Tertiary centres
- Vocational Services
The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Who will use ASSIST
Health Psychologist Health Residents
Professionals Counsellors Educators ANM
Midwives Interns General Welfare
General
Practitioners Nurses
Social workers
ASSIST-BI helps to make health providers confident, takes
less time and give a direction about how to screen as well
as counsel in more objective way even in a busy Schedule
The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, 372
Australia ASSISTportal.com.au
The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Summary
● ASSIST is validated 8 item questionnaire developed by
World Health Organization
● Screens 10 substances and assign a risk category for
each substance (Low-Moderate-High risk)
● Linked with Brief Intervention to help the people about
how to reduce or stop the substances
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Familiar with name of Substances and street names
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
The Responses
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The ASSIST Portal: WHO Collaborating Centre, Adelaide, South Australia, Australia ASSISTportal.com.au
Practice (zoom quiz 1)
1. Someone who drank alcohol Everyday except Thursday
in last three months should be recorded as
a. Never
b. Once or twice
c. Monthly
d. Weekly
e. Daily or almost Daily
-
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The Responses
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Practice (zoom quiz 2 )
1. Someone who has used Cannabis twice in last three
months
a. Never
b. Once or twice
c. Monthly
d. Weekly
e. Daily or almost Daily
-
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The Responses
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Demo of e-ASSIST
https://assistportal.com.au/eassist/
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CASE VIGNETTE
36 yrs , married male, currently unemployed presented with alcohol consumption since last 10 yrs increased since last 4 yrs. Currently he takes
about 750 ml of whisky per day. He also takes tobacco since age of 16. He currently smokes about 7-8 cig/day. He tells he has experimented
with various drugs like cocaine, cannabis, LSD, MDMA, mushrooms in his college days (around 5yr back). He physically and verbally abuses his
family members under the influence of alcohol and has not been able to work because of his drinking behaviour.He says he has a strong urge to
take tobacco and alcohol due to which he is unable to quit them even though he has tried multiple times. His family members are concerned
about him and want him to seek help for this.
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LOW ASSIST HIGH
General Health Advice LEVEL OF RISK Brief Intervention
Take home information
MODERATE Referral to Specialist
assessment & treatment
Brief Intervention
Take Home Information
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TAKE HOME MESSAGE
• Opportunities for screening, early detection, and brief
intervention for Substance use disorders exist in many
settings
• Use of ASSIST and Brief Intervention is the first stage of
engagement
• Easy and culturally appropriate screening tool which also
guides about type of intervention
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FURTHER READING
1. https://www.who.int/substance_abuse/ac
tivities/assist_test/en/
2. https://assistportal.com.au/
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Thank YOU
3
8
Managing Alcohol Withdrawal:
Simple
Presenter: Dr. Deepak S. Ghadigaonkar
MD Psychiatry
PDF in Addiction Psychiatry
389
Clinical Vignette 1
• Mr. A, 48 yr, Male, studies upto SSLC, working as
a daily wage labourer, rural Karnataka
• h/o alcohol use since 22 years of age, starting with
3 units (90ml) with friends, would feel relaxed and
euphoric after drink, gradually increasing the
intake to 12 units
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Contd…
• He would frequently get intense desire to consume
alcohol, and would keep thinking about ways to
get next drink, often missed work
• Later started having tremors of hands, intense
sweating, early in the morning, which would
increase as day progressed, forcing him to take
alcohol earlier, morning drinking
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Contd…
• Anxious if not drinking, relaxed as soon as he
drank
• Sleep disturbed if did not have a drink
• Frequent attempts to quit drinking, failed
• Compulsion to drink rather than enjoyment
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Contd…
• Stopped drinking for 2 days because of religious
function at native place
• On the second day afternoon, seizure (GTCS), was
taken to hospital, second seizure in the hospital,
was treated with vitamins and sent home
• Developed fearfulness, started talking irrelevantly,
picking something out of air
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Contd…
• Was brought to NIMHANS
• Not oriented to Time/ Place, oriented to person
• Agitated, fearful, trying to run away from the ward
• Tremulous, sweating
• Pulse: 128 bpm, BP: 138/96 mmHg
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Sli.do question
• Which of the following is not assessed as a part of
scoring in Clinical Institute Withdrawal
Assessment for Alcohol Scale, Revised
(CIWA-Ar):
A. Tremors
B. Nausea/ Vomiting
C. Pulse rate
D. Headache/ Fullness in head
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Learning Objectives
• What is withdrawal?
• Neurobiology of withdrawal
• Timeline/ Identification of withdrawal
• Assessment
• Management (Detoxification)
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Diagnosing SUD?
1. Impaired control
2. Social Impairment
3. Risky use
4. Pharmacological criteria
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How to diagnose SUD?
Pharmacological criteria
Use despite knowledge of harm
Tolerance
Withdrawal symptoms
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Withdrawal
• The development of substance specific
maladaptive behavioural change, usually with
uncomfortable physiological and cognitive
consequences, i.e., the result of a cessation of, or a
reduction in, heavy and prolonged substance use.
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Contd…
• The signs and symptoms of withdrawal are
opposite of substance direct effect.
• The onset, duration and intensity of withdrawal are
variable and depend on the agent used, the duration
of use and degree of neuro-adaptation.
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